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PRINCIPLES  OF 
MEDICAL  TREATMENT 

By 

GEORGE  CHEEVER  SHATTUCK,  M.D.,  A.M. 

Assistant  Professor  of  Tropical  Medicine,  Harvard  Medical  School 
Formerly  Assistant  Visiting  Physician,  Massachusetts  General  Hospital 


FIFTH  REVISED  EDITION 

WITH   CONTRIBUTIONS    BY  THE    FOLLOWING  AUTHORS 

TUBERCULOSIS 

John  B.  Hawes,  2d,  M.D. 

Assistant  Visiting  Physician  and  Director  of  the  CHnic  for  Pulmonary  Diseases 

Massachusetts  General  Hospital 

Consultant  for  Diseases  of  the  Chest  for  the  New  England  District  of  the 

United  States  Public  Health  Service 

ACUTE  INFECTIOUS  DISEASES  MOST  COMMON  IN 
CHILDHOOD 

Edwin  H.  Place,  M.D. 

Physician  in  Chief  of  South  (Contagious)  Department,  Boston  City  Hospital 
Assistant  Professor  of  Pediatrics,  Harvard  Medical  School 

INFLUENZA 

Gerald  Blake,  M.D. 

Associate  in  Medicine,  Massachusetts  General  Hospital 
Instructor  in  Medicine,  Harvard  Medical  School 

DIABETES  MELLITUS 
Benjamin  H.  Ragle,  M.D. 

Assistant  Physician  to  Out-Patients,  Massachusetts  General  Hospital 

SERUM  TREATMENT  OF  PNEUMONIA 
Henry  M.  Thomas,  Jr.,  M.D. 

Resident  Physician  Johns  Hopkins  Hospital 


BOSTON: 

W.  M.  LEONARD,  INC.,  Publishers 

1921 


Copyright,  1921 
By  W.  M.  Leonard,  Inc. 


TO 

WILLIAM  HENRY  SMITH,  M.D. 

TEACHER   IN  MEDICINE 

AND 

FRIEND  TO  MANY 


PREFACE. 


This  work  represents  an  attempt  to  offer  clearly  and  concisely 
sound  principles  of  treatment  based  on  known  pathology.  The 
methods  described  are  selected  from  those  that  have  been  tried 
at  the  Massachusetts  General  Hospital  or  in  private  practice. 
Most  of  them  have  been  taught  by  Prof.  F.  C.  Shattuck,  Dr. 
William  H.  Smith  or  others  on  the  staflF  of  the  Hospital  or  of  the 
Haivard  Medical  School.  It  is  not  to  be  supposed  that  any  of 
these  men  subscribe  fully  to  every  thing  here  set  forth  or  that 
further  advance  will  not  require  revision. 

The  writer  wishes  here  to  express  his  deep  appreciation  of  the 
debt  which  he  owes  to  his  teachers  in  medicine,  of  their  kindliness 
to  pupils  and  of  their  humanity  to  patients. 

Brevity  being  essential  to  the  writer's  purpose,  this  synopsis 
is  necessarily  incomplete.  The  book  was  prepared  primarily 
for  use  in  the  Harvard  Medical  School. 

G.  C.  S. 


PREFACE  TO  SECOND  EDITION. 


In  this  edition,  as  in  the  first,  completeness  has  been  sacrificed 
to  brevity,  but  new  material  has  been  added  and  many  changes 
have  been  made. 

More  reliance  than  before  has  been  placed  on  personal  ex- 
perience, but  the  information  about  salvarsan  was  derived, 
chiefly,  from  recent  literature. 

It  is  a  pleasure  to  acknowledge  the  assistance  and  helpful 
criticism  of  fi lends  and,  notably,  that  of  Mr.  Godsoe,  Phar- 
macist of  the  Massachusetts  General  Hospital. 

G.  C.  S. 


[5] 
PREFACE  TO  THIRD  EDITION. 


This  book  has  grown  considerably  since  the  first  edition 
appeared,  and  the  original  name,  "  A  Synopsis  of  Medical  Treat- 
ment "  has  been  criticized  on  the  ground  that  it  gave  an  inade- 
quate idea  of  the  scope  of  the  book.  I  was  the  more  ready  to 
change  the  title  because,  from  the  first,  it  has  been  my  desire  to 
subordinate  methods  and  to  emphasize  principles.  Accordingly 
the  name  of  the  book  has  been  changed  to  "  Principles  of  Medical 
Treatment." 

I  count  it  a  piece  of  rare  good  fortune  to  be  able  in  this  edition 
to  publish  new  material  on  some  of  the  acute  infections  by  Dr. 
Edv/in  H.  Place  and  on  tuberculosis  by  Dr.  John  B.  Hawes,  2d, 
men  whose  work  in  their  respective  fields  is  so  favorably  known 
as  to  render  comment  unnecessary. 

G.  C.  S. 


PREFACE  TO  FOURTH  EDITION. 


Doctor  Shattuck's  continued  absence  in  France  has  prevented 
more  than  a  careful  revision  of  his  text  for  minor  corrections. 
Doctor  Place  and  Doctor  Hawes  have  revised  and  added  to  the 
text  of  the  sections  written  by  them  for  the  previous  edition. 

W.  M.  L. 


PREFACE  TO  FIFTH  EDITION. 


The  scope  of  the  book  in  this  edition  has  been  extended  in 
important  directions  by  new  contributions  from  Drs.  John  B. 
Hawes,  2d,  Edwin  H.  Place,  Gerald  Blake,  B.  Harrison  Ragle 
and  Henry  M.  Thomas,  Jr. ;  and  the  old  text  has  been  modified 
or  amplified  in  many  particulars. 


16] 

Attention  is  directed  to  the  views  expressed  under  the  head  of 
circulatory  disorders  in  the  infectious  diseases.  This  subject 
is  still  so  imperfectly  understood  that  to  treat  it  on  the  basis  of 
established  principles  seems  out  of  the  question.  Consequently 
it  has  seemed  best  to  advance  personal  views  and  to  invite  criti- 
cism or  suggestions  from  any  interested  member  of  our  profession 
in  the  hope  of  ultimately  throwing  more  light  into  this  dark 
corner  of  medical  practice. 

Being  no  longer  a  member  of  the  Staff  of  the  Massachusetts 
General  Hospital  and  not  having  been  for  several  years  in  close 
touch  with  its  work,  no  claim  is  made  that  my  contributions 
represent  the  practice  now  prevailing  there. 

Special  acknowledgments  are  due  to  Dr.  William  Henry  Smith, 
Visiting  Physician,  to  Mr.  Joseph  Godsoe,  Pharmacist  of  the 
Massachusetts  General  Hospital  and  to  Miss  Alice  B.  Newell, 
who  has  exercised  the  most  painstaking  care  in  preparing  the 
manuscript. 

G.  C.  S. 


CONTENTS  AND  INDEX. 

PAGE 

Preface 4 

Chapter  I. 

DISORDERS  OF  THE  CIRCULATORY  SYSTEM. 

Cardiac  Insufficiency. 

Principles  of  Treatment 17 

Methods  of  Treatment 17 

Rest 17 

Depletion 17 

Stimulation 19 

Diet 21 

Regulation  of  Mode  of  Life 23 

Valvular  Disease: — 

Classification  of  Valvular  Disease 23 

Pathology  and  Diagnosis 23 

Prevention  of  Recurrence 25 

Treatment  for: 

I     Congenital  and  Obsolete  Infectious  Valve 

Lesions 27 

II    Active  Infectious  Lesions 27 

III  Syphilitic  Valve  Lesions 29 

IV  Degenerative  Valve  Lesions 29 

Hypertension  with  Cardiac  Insufficiency 29 

Pulmonary  Edema 

I    With  Hypertension 31 

II    Without  Hypertension 23 

Circulatory  Disorders  of  Infectious  Fevers  and  Sepsis. 

A    General  Circulatory  Disorders  : 

Prophylaxis  in  General 37 

Symptomatic  Treatment. 37 

Circulatory  Collapse 43 


B    Myocardial  Disorders:  page 

Infection 45 

Heart-block 45 

Malnutrition 47 

Sudden  death 47 

C    Disorders  of  the  Pulmonary  Circulation: 

Toxemic  Edema 47 

Obstructive  Lesions 49 

Angina  Pectoris: — 

Classification 51 

Diagnosis 51 

Syphilitic  Angina: — 

Treatment  in  General 53 

Treatment  of  Attack ^;^ 

Degenerative  Angina: — 

Treatment ^^ 

Kmbolic  Angina:  Treatment ^^ 

Neurotic  Angina:  Treatment ^^ 


CR\PTER  II. 
NEPHRITIS. 


PAGE 


Classification 57 

Pathology  and  Diagnosis 57 

Acute  Renal  Irritation:  Treatment 61 

Acute  Nephritis: — 

Principles  of  Treatment 61 

Methods  of  Treatment: 

Sweating 63 

Purgation 63 

Diet 65 

Liquids 65 

Nutrition 6c; 

Exposure 65 

Medication 65 


[9\ 

PAGE 

Prophylaxis 67 

Uremia 67 

Chronic  Nephritis: — 

Principles  of  Treatment 67 

Methods  of  Treatment 67 

Syphilitic  Nephritis 69 

Arteriosclerotic  Degeneration '.Treatment 69 

Passive  Congestion: Treatment 71 

Uremia : — 
Methods  of  Treatment 71 

Chapter  III. 
ACUTE  INFECTIOUS  DISEASES. 


PAGE 


Principles  of  Treatment  for  Acute  General  Infec- 
tions    75 

Typhoid  Fever. 

Principles  of  Treatment 77 

Prophylaxis 77 

Methods  of  Treatment 77 

Dilution  AND  Elimination  of  Toxins 77 

Conservation  of  Strength 79 

Diet 79 

Medication 81 

Observation 83 

Nursing 83 

Convalescence 87 

Symptomatic  Treatment: — 

Fever  and  Toxemia 87 

Circulatory  Disorders 89 

Diarrhea 89 

Constipation 89 

Distention 91 

Vomiting 91 

Headache 91 

Complications,  Treatment  of: — 

Hemorrhage 91 

Perforation 93 


[lo] 
Rheumatic  Fever. 

PEGE 

Principles  of  Treatment 93 

Methods  of  Treatment 93 

Chapter  IV. 
ACUTE  INFECTIONS  MOST  COMMON  IN  CHILDHOOD. 

By  Edwin  H.  Place,  M.D. 

Scarlet  Fever. 

PAGE 

Manner  of  Spread 99 

Prophylaxis 99 

Immunity loi 

Asepsis loi 

Isolation loi 

Quarantine 103 

Disinfection 103 

Treatment: 

Toxemia : 103 

General  Sepsis 105 

Local  Sepsis 107 

Nephritis 113 

Cardiac  Complications 113 

Fever 115 

Measles. 

Manner  of  Spread 115 

Prophylaxis 115 

Treatment: —  . 

Acute  Toxemia 117 

Mucous  Membrane  Infections 119 

Pertussis. 

Manner  of  Spread 121 

Prophylaxis 123 

Treatment 1 23 

Varicella. 

Manner  of  Spread 127 


[II] 

PAGE 

Prophylaxis 127 

Treatment 127 

Diphtheria. 

Manner  of  Spread 129 

Prophylaxis  : — 

Immunity 1 29 

Asepsis 129 

Isolation 131 

Quarantine 131 

Treatment  : — 

Toxemia 133 

Obstruction  to  Breathing 133 

Local  Treatment 133 

Complications  : — 

Cardiac 135 

Paralysis 137 

Chronic  Obstruction  of  Larynx 137 

Serum  Disease 137 

Carriers 139 


Chapter  V. 
ACUTE  INFECTIONS  OF  RESPIRATORY  TRACT. 
Lobar  Pneumonia. 


PAGE 


Principles  of  Treatment 141 

Methods  of  Treatment 141 

Stimulation  of  Heart 143 

Delirium:  Treatment 143 

The  Serum  Treatment  of  Pneumonia. 

By  Henry  Malcolm  Thomas,  Jr.,  M.D. 

Method  of  Administration 145 

Determination  of  Sensitiveness 147 

Desensitization  in  positive  skin  test 147 

Desensitization  in  negative  skin  test 147 


[12] 

PAGE 

Administration  of  Type  I,  Antipneumococcus  Serum  149 

Number  and  Frequency  of  Treatments 149 

Serum  Reactions 151 

Anaphylactic 151 

Thermai 151 

Serum  Disease 1 53 

Sections  Revised  by  Gerald  Blake,  M.D. 

Broncho-pneumonia 1 53 

Bronchitis,  acute 155 

Bronchitis,  chronic 157 

Bronchiectasis 157 

Acute  Inflammation  of  the  Upper  Respiratory  Tract. 

Revised  by  Gerald  Blake,  M.D. 

Etiology 161 

Complications  and  Sequelae 161 

Diagnosis 161 

Prophylaxis 163 

Treatment  in  General 163 

Treatment  for  Varieties  of  Types 165 

Pharyngitis 165 

CoRYZA 165 

Tonsillitis 167 

Laryngitis 167 

Tracheitis 167 


INFLUENZA. 

By  Gerald  Blake,  M.D. 

Nature  and  varieties 169 

Prophylaxis 171 

Treatment  IN  General 171 

Treatment  for  Varieties  of  Types 171 

Serum  from  Convalescents 173 

Complications 175 


[13  J 

Chapter  VI. 
PULMONARY  TUBERCULOSIS. 

By  John  B.  Hawes,  2d,  M.D. 

PAGB 

Etiology 177 

Course  of  disease 177 

Complications  and  Sequelae 179 

Diagnosis 179 

Prophylaxis 1 87 

Treatment  in  General 189 

Sanatorium  Treatment 191 

Home  Treatment 197 

Climate 199 

Tuberculin 201 

Heliotherapy 203 

Drugs 203 

Tuberculosis  in  Children 203 

Non-Pulmonary  Tuberculosis 205 

The  Tuberculosis  Problem 207 

Chapter  VII. 
GASTRO-INTESTINAL  DISORDERS 
Gastric  and  Duodenal  Ulcer. 


PAGE 


Indications  for  Medical  Treatment 211 

Principles  of  Treatment 211 

Methods  of  Treatment 211 

Diet 211 

Complications, Treatment  of: — 

Hemorrhage 215 

Perforation 217 

Pyloric  Obstruction 217 

Persistent  Severe  Symptoms 217 

Acute  Indigestion. 

Diagnosis 221 


I  14] 

PAGE 

Principles  of  Treatment 221 

Methods 221 

Simple  Diarrhea. 

Diagnosis 225 

Principles  of  Treatment 227 

Methods  of  Treatment 227 

Medication 227 

Constipation. 

Classification 229 

Principles  of  Treatment 231 

Methods  : — 

Spasmodic  Constipation 231 

Atonic  Constipation 233 

Obstructive  Constipation 235 

Various 235 


Chapter  VIII. 
DIABETES  MELLITUS. 

Bv  B.  Harrison'  Ragle,  M.D. 

PAGE 

Principles  of  Treatment 239 

Methods  of  Treatment 239 

Gradual  Reduction  of  Diet 239 

Fasting 245 

Acidosis 245 

Treatment  of  Coma 247 

Complications  in  Diabetes 247 

Etiology  of  Diabetes 249 

Diabetes  in  Children 251 

Transitory  Glycosuria 253 

Renal  Diabetes 253 

Exceptional  Diabetes 253 

Notes 253 


[15] 

Chapter  IX. 

MEDICATION. 

Foreword 257 


PAGE 


List  I.     Very  Valuable  Drugs. 

Action  and  Uses  of  : — 

1.  Arsphenamine 259 

2.  Mercury 265 

3.  Iodide  of  Potash 269 

4.  Diphtheria  Antitoxin 271 

5.  Morphine 271 

6.  Digitalis 275 

7.  Nitroglycerin  and  nitrites 28 1 

8.  Theobromine 283 

9.  Magnesium  sulphate 283 

10.  Quinine 285 

1 1 .  Salicylates 287 

12.  Hexamethylanamine 289 


List  n.    Valuable  Drugs  and  Non-medicinal  Preparations. 

Action  and  Uses  of  and  substitutes  for: 

1.  Pills  of  Ferrous  Carbonate,  "  Blaud's  Pills  "  293 

2.  Sulphonethylmethane,  "  Trional  " 293 

3.  Bromides 293 

4.  Acetphenetidin 293 

5.  Powder  of  Ipecac  and  Opium 295 

6.  Codeine 295 

7.  Sodium  Bicarbonate 295 

8.  Bismuth  Subnitrate 295 

9.  MildMercurous  Chloride,  "  Calomel  " 295 

10.  Castor  Oil 297 

1 1 .  Cascara  Sagrada 297 

12.  "Russian  Oil" 297 

13.  Agar 299 

14.  Vaccine  Virus 299 


[i6] 

PAGE 

15.  Antityphoid  vaccine 299 

16.  Tuberculin 301 

17.  Normal  Salt  Solution 301 

18.  Alcoholic  Beverages 301 

List  of  Drugs  Commonly  Useful 303 

Lists  of  Drugs  Valuable  for  Occasional  Use 305 

Tables  of  Weights  and  Measures 305 

Abbreviations 309 


[I?] 


CHAPTER  I. 
DISORDERS  OF  THE  CIRCULATORY  SYSTEM. 

CARDIAC  INSUFFICIENCY. 
GENERAL  PRINCIPLES  OF  TREATMENT. 

A.  Rest. 

B.  Depletion. 

C.  Stimulation. 

D.  Suitable  Diet. 

E.  Regulation  of  Mode  of  Life. 

The  principles  are  much  the  same  whatever  the  underlying 
cause.  Treatment  must,  however,  be  regulated  to  suit  the 
severity  of  syinptoms,  to  meet  individual  needs,  and  for  varieties 
of  disease. 

An  exact  diagnosis  may  be  difficult  in  the  presence  of  severe 
insufficiency  and  may  not  be  necessary  at  first,  but  accuracy  in 
diagnosis  is  very  important  for  prognosis  and  for  planning  treat- 
ment for  the  future. 

METHODS  OF  TREATMENT. 

A.  Rest. 

1 .  Semi-recumbent  position  in  bed  or  chair. 

2.  Minimum  exertion. 

3.  Relieve  discomfort  and  secure  sleep.  If  there  is  much  dis- 
comfort morphine  subcutaneously  is  indicated. 

B.  Depletion. 

1.  Purgation.  Obtain  watery  catharsis  more  or  less  profuse 
according  to  amount  of  edema. 

When  edema  is  absent  or  slight  avoid  excessive  purgation  lest 
exhaustion  result. 
Magnesium  sulphate  (p.  283)  is  useful  as  a  purgative. 

2.  Limitation  of  Liquids.  Total  liquids,  including  liquid  foods, 
should  not  exceed  three  pints  in  twenty-four  hours.  One  pint  in 
twenty-four  hours  is  near  the  minimum.  The  patient  should  not 
be  allowed  to  suffer  from  thirst.     It  may  be  relieved  by  sucking 


[19] 

cracked  ice,  by  gargling  or  by  the  use  of  chewing  gum  unless 
dyspnoea  prevents. 

3.  Diuresis  should  follow  the  use  of  digitalis  when  there  is 
cardiac  edema.  In  mild  cases  of  insufficiency,  rest,  purga<-ion  and 
limitation  of  liquids  without  digitalis  may  suffice. 

When  edema  is  persistent  or  extreme,  diuretics  should  be  pre- 
scribed. Theobromine  (p.  283)  or  its  substitutes  may  be  expected 
to  act  well  provided  the  kidneys  are  not  severely  damaged. 
"  Calomel  "  should  not  be  given  if  the  patient  has  nephritis  be- 
cause salivation  may  result.  Theophylline  may  act  better  than 
theobromine  in  some  cases. 

4.  Venesection.  Indicated  occasionally  when  there  is  engorge- 
ment of  the  right  ventricle  with  marked  evidence  of  venous  stasis; 
e.g.^  dyspnoea,  cyanosis,  pulmonary  edema  and  engorgement  of 
neck-veins  and  liver. 

A  pint  of  blood  or  even  more  may  be  withdrawn.  Venesection 
is  contraindicated  by  emaciation  or  by  marked  weakness  or 
anemia.  Blood  is  generally  withdrawn  by  incising  a  vein  on  the 
inner  side  of  the  elbow.  A  tourniquet  may  be  put  around  the 
arm  to  render  the  veins  prominent.  The  incision  should  be  made 
in  the  long  axis  of  the  vein  with  the  point  of  a  sharp  knife.  The 
bleeding  can  be  stopped  with  a  pad  and  bandage.  Suturing  the 
vein  is  unnecessary.  The  blood  can  be  withdrawn  from  the  vein 
by  aspiration  if  a  suitable  apparatus  is  at  hand. 

5.  Leeching.  Useful  as  a  substitute  for  venesection  when  the 
latter  would  be  undesirable  or  when  symptoms  are  less  severe. 
Leeching  will  generally  relieve  painful  engorgement  of  the  liver. 

Apply  a  dozen  leeches  over  the  right  hypochondrium  and  allow 
them  to  remain  until  they  drop  off.  The  abdomen  should  then 
be  covered  with  a  large,  moist,  absorbent  dressing  to  favor  oozing 
from  the  bites.  A  drop  of  milk  placed  on  the  skin  encourages 
the  leech  to  bite.     Salt  causes  him  to  let  go. 

6.  Tapping.  Necessary  when  fluid  in  the  chest  or  abdominal 
cavity  seriously  embarrasses  the  heart  or  respiration. 

C.   Stimulation. 

Digitahs  is  the  cardiac  "  stimulant  "  par  excellence  but  it  may 
be  more  accurately  spoken  of  as  a  tonic.  An  active  preparation 
in  sufficient  dose  does  good  in  almost  any  variety  of  cardiac  in- 


[21] 

sufficiency.  The  most  marked  benefit  may  be  expected  in  severe 
cases  of  auricular  fibrillation  or  flutter. 

Circulatory  disturbances  in  the  acute  infectious  diseases  are 
comparatively  little  influenced  by  digitalis.  Rarely,  failure  to 
get  improvement  from  digitalis  is  due  to  chronic  lesions  of  the 
myocardium  so  extensive  that  the  heart  is  incapable  of  further 
response. 

It  is  generally  true  that  if,  after  pushing  digitalis  in  a  suitable 
case,  neither  benefit  nor  toxic  effect  follows  within  a  few  days  the 
'preparation  is  probably  inactive. 

For  further  information  about  the  use  of  preparations  of  the 
digitalis  group  and  about  their  use  in  emergencies,  see  digitalis, 
p.  275. 

Slight  recurring  exacerbations  of  dyspnoea  seem  often  to  be 
relieved  promptly  by  the  use  of  a  quickly  diffusible  stimulant. 
The  following  may  be  tried: 

By  mouth : 

{a)   Spiritus  ammoniae  aromaticus  (U.  S.):    i  drach.  (or  4 

mils). 
(^)    Whiskey  or  brandy:  from  \  to  i  oz.  (or  15  to  30  mils). 
Subcutaneously: 

(<:)    Camphor  in  oil:*  3  grs.  (or  0.2  gm.).     Inject  intramuscu- 
larly. 
{d)   Cocaine  hydrochloride:  from  |  to  |  gr.  (or  0.008  to  0.016 
gm.).     It  is  said  to  be  dangerous  but  may  act  very 
well. 
Insufficiency  with  much  pain  requires  morphine  (p.  271).     It 
seems  to  act  under  these  circumstances  as  an  efficient  cardiac 
stimulant.     It  brings  also  physical  comfort  and  psychic  relief 
which  favor  recuperation.     The  morphine  should  be  used  subcut. 
under  these  circumstances  to  ensure  prompt  effect. 

D.   Diet. 

Spare  the  patient  unnecessary  effort,  particularly  if  there  is 
much  dyspnoea,  by  ordering  food  which  is  easy  to  swallow  and 
which  requires  no  chewing. 

By  frequent  small  feedings  and  by  avoiding  gas-producing 
foods  seek  to  prevent  cardiac  embarrassment  from  distention. 

*  Shpuld  be  specially  prepared  for  subcut.  use. 


[23] 

Emaciated  patients  should  take  as  much  concentrated  nourish- 
ment as  is  practicable  in  order  to  strengthen  the  heart  muscle  by 
improved  nutrition. 

Fat  or  plethoric  individuals  may  benefit  by  fasting. 

The  Karell  diet  combines  the  principle  of  limitation  of  fluid 
intake  with  that  of  relative  starvation.  It  is  suitable  for  well 
nourished  patients  with  edema.  The  chief  disadvantage  is  its 
monotony  for  the  patient. 

E.   Regulation  of  Mode  of  Life. 

To  prevent  relapse  during  and  after  convalescence,  the  mode 
of  life  of  the  patient  must  be  wisely  regulated;  and  intelligent 
cooperation  between  patient  and  physician  is  essential  to  this  end. 
It  is  generally  necessary  to  tell  the  patient  something  about  his 
condition  and  to  warn  him  to  avoid  activities  which  induce  much 
fatigue  and  exertions  which  cause  much  dyspnoea.  Judgment 
and  caution  must  be  exercised  in  dealing  with  an  apprehensive 
patient  lest  danger  be  exaggerated  in  his  mind,  and  harm  result. 

After  a  sufficient  period  of  complete  rest  the  patient  should  be 
encouraged  to  take  regular  exercise  within  the  limits  of  tolerance 
in  order  to  strengthen  the  heart  by  promoting  hypertrophy; 
except  that  when  coronary  circulation  is  much  impaired  exercise 
is  to  be  avoided.     See  angina  pectoris,  p.  51. 

Exercise  and  work  should  be  resumed  very  gradually  under 
close  supervision. 

VALVULAR  DISEASE. 
CLASSIFICATION. 

1.  Congenital   .      .    j  Most    commonly    discovered    in    early 

{      childhood. 

2.  Infectious     .      .       Most  commonly  discovered  in  youth. 

3.  Svphilitic      .      .     \  Most  commonly  discovered  in  middle 

\      hfe. 

4.  Degenerative     .       Most  commonly  discovered  in  old  age. 

PATHOLOGY  AND  DIAGNOSIS. 

Note. —  Any  of  the  lesions  enumerated  below  may  be  compen- 
sated when  first  seen,  but  cardiac  insufficiency  generally  follows 
in  time.  The  chief  determining  factor  is  the  severity  of  associated 
myocardial  damage. 


[25] 

I.    Congenital  lesions.     Pulmonic  stenosis  is  the  most  common. 
It  is  seldom  mistaken  for  other  t>^pes  of  lesion  but  may  easily  be 
confused  with  anomalies  which  have  similar  signs  and  which  are 
often  combined  with  it. 
1.   Infectious  lesions. 

{a)   Active  stage.     Inflammation  of  valves  due  to  presence 

of  bacteria  on  the  valve. 
{b)    Obsolete  stage.    Valves  deformed  and  scarred  as  a^re- 

sult  of  inflammation. 
{c)    Recurrent  stage.     Reinfection  with  inflammation  at  site 
of  old  lesion. 
Lesions  are  found  commonly  at  the  mitral  valve  or  at  the  aortic 
and  mitral  valves,  seldom  at  the  aortic  valve  alone.     Occasion- 
ally  the  mitral,   aortic   and   tricuspid  valves   are   all   diseased. 
Stenosis  develops  frequently.     Stenosis  at  the  aortic  and  mitral 
valves  suggests  tricuspid  stenosis  as  well. 

Obsolete  lesions  if  well  compensated  may  give  no  symptoms. 
They  first  attract  attention  by  diminished  cardiac  efficiency  or  by 
failure  of  compensation. 

In  the  active  or  recurrent  stage  the  symptoms  are  those  of 
general  infection  with  or  without  failure  of  compensation. 

3.  Syphilitic  lesions.  The  lesion  generally  begins  in  the  as- 
cending aorta  and  extends  subsequently  to  the  aortic  valve.  The 
earliest  signs  may  be  slight  dilatation  of  the  arch  and  the  murmur 
of  aortic  roughening.  Later,  that  of  aortic  regurgitation  may 
appear  and,  finally,  relative  mitral  regurgitation  may  develop. 

A  lesion  of  the  aortic  valve  only,  in  a  young  adult,  suggests 
syphilis  as  its  cause.  Aneurism  or  coronary  endarteritis  may 
coexist  as  part  of  the  same  process. 

Evidence  of  an  old  syphilis  supports  the  diagnosis. 

4.  Degenerative  lesions.  As  in  syphilis,  the  signs  point  to  a 
lesion  at  the  aortic  valve  but  evidence  of  syphilis  is  lacking.  The 
background  is  one  of  senility  and  general  arteriosclerosis  to  which 
sclerosis  of  the  aorta  and  of  the  aortic  valve  is  incidental.  There 
may  be  dilatation  of  the  arch  and  evidence  of  myocardial  degenera- 
tion, perhaps  also  angina  pectoris. 

PREVENTION  OF  RECURRENCE. 

{a)  Search  for  and  eliminate  all  foci  of  infection  in  sinuses, 
teeth,  tonsils,  or  genito-urinary  tract. 


[27] 

(J?)  Diseased  tonsils,  as  a  rule,  should  be  removed  at  the  first 
suitable  opportunity.  It  is  dangerous  to  remove  them  when 
acutely  inflamed. 

{c)  Warn  the  patient  against  exposure  and  insist  that  he 
attend  promptly  to  ailments,  even  if  slight,  and  avoid  mental 
strain,  and  any  physical  exertion  which  produces  dyspnoea  or 
fatigue. 

TREATMENT. 

I.  Congenital  and  Obsolete  Infectious  Lesions  of  Valves. 

Treat  according  to  the  general  principles  given  above. 
They  must   be  modified   for   the   individual  with   regard   to 
severity,  duration,  nature  and  cause  of  symptoms. 

II.  Active  Infectious  Lesions  of  Valves. 

A.  Principles  of  Treatment.  As  for  acute  infections  in  general 
(p.  75)  and  for  cardiac  insufficiency  if  present. 

I.  Rest  in  bed. 

1.  Minimum  exertion. 

3.  Dilution  of  toxins. 

4.  Elimination  of  toxins. 

5.  Maintenance  of  nutrition. 

6 .  S timulation  p.r.n. 

Note. —  The  infection  may  be  acute,  subacute  or  recurrent. 
The  chief  dangers  are  from  toxemia,  exhaustion,  cardiac  dilatation 
or  embolism. 

Evidence  of  recent  preexisting  rheumatic  fever,  chorea  or 
tonsillitis  strengthens  a  diagnosis  of  active  endocarditis. 

B.  Methods,  {a)  Good  nursing  is  very  important.  The 
nurse  should  promote  comfort  by  attention  to  details,  should  feed 
the  patient  and,  whenever  possible,  spare  him  exertion  or  annoy- 
ance. 

ijy)  To  dilute  toxins  and  to  favor  elimination  order  abundance 
of  liquids.  Have  intake  and  output  recorded.  If  cardiac  dila- 
tation threatens  or  if  there  is  edema  liquids  must  be  restricted. 

(c)  Feedings  should  be  frequent,  the  food  nutritious,  and  the 
amount  regulated  by  digestive  power.  Liquids  and  soft  solids 
are  preferable  in  severe  cases  because  easy  to  swallow. 


{d)  Stimulants  are  to  be  avoided  unless  clearly  necessary  be- 
cause embolism  is  to  be  feared  and  stimulation  might  favor  it. 

{e)  Tachycardia  may  sometimes  be  reduced  by  an  ice-bag 
placed  over  the  praecordia. 

C.  Convalescence.  To  minimize  danger  of  relapse  keep  the 
patient  in  bed  and  as  quiet  as  possible  for  weeks  or  months  after 
the  pulse  and  temperature  have  returned  to  normal.  Permanent 
damage  nearly  always  remains.  The  degree  of  possible  improve- 
ment depends  on  the  location  and  extent  of  the  lesions  and  on  the 
recuperative  power  of  the  patient.  Therefore,  guard  against 
strain,  and  treat  malnutrition  or  anemia,  if  present,  to  promote 
hypertrophy  of  the  heart. 

III.  Syphilitic  Lesions  of  Valves  require  antisyphilitic  medica- 
tion as  well  as  general  measures  for  cardiac  insufficiency. 

Little  improvement  can  be  expected,  however,  unless  the 
diagnosis  be  made  before  extensive  and  irreparable  damage  has 
occurred. 

IV.  Degenerative  Lesions  of  Valves  may  be  treated  on  general 
principles  with  certain  modifications  as  follows: 

{a)  When  blood-pressure  is  high,  nitrites  may  be  of  value  to 
lighten  the  work  of  the  heart  by  lowering  pressure  temporarily. 

{b)  Thin  patients  require  the  maximum  nutrition  to  strengthen 
the  heart.  They  should  undergo  little  or  no  purgation  unless 
edema  is  considerable. 

{c)  Regulation  of  life  is  of  the  utmost  importance  during  and 
after  convalescence.     The  patient's  cooperation  must  be  secured. 

{d)  Many  of  these  patients  should  take  digitalis  and  salts  more 
or  less  frequently  for  long  periods  or  for  the  rest  of  their  lives. 
The  best  dosage  for  the  individual  can  be  determined  only  by  trial. 
Several  small  doses  per  week  taken  at  regular  intervals  may  be 
sufficient.  Warn  the  patient  not  to  be  without  his  medicine  or 
to  give  it  up  on  his  own  responsibility.  The  heart  muscle  may, 
perhaps,  be  so  changed  that  it  cannot  respond  to  any  form  of 
treatment. 

HYPERTENSION  WITH  CARDIAC  INSUFFICIENCY. 

Etiology  and  Symptoms.  Hypertension  is  commonest  in 
chronic  nephritis  and  is  seen  also  in  arteriosclerosis.    The  hyper- 


[31] 

tension  and  left  ventricular  hypertrophy  develop  gradually. 
Symptoms  of  insufficiency  often  increase  so  gradually  as  to  be 
disregarded  by  the  patient  for  months.  The  condition  of  the 
patient  is  generally  more  critical  than  the  signs  would  seem  to 
indicate.  Acute  pulmonary  edema  is  common  in  these  cases. 
Many  of  them  show  signs  of  toxemia  attributable  to  deficient 
renal  elimination. 

Treatment,     i.   Methods  for  cardiac  insufficiency  (p.  17). 

2.  Reduce  the  work  of  the  heart  by  lowering  blood-pressure 
temporarily  unless  the  urinary  output  falls  in  consequence. 

{a)  Vaso-dilators,  e.g.,  nitroglycerin  (p.  281),  lower  blood- 
pressure  temporarily  and  often  promote  diuresis  also. 

{b)  Purgation,  diuresis,  venesection  and  measures  tending 
to  relieve  toxemia  or  to  improve  the  circulation  seem 
to  favor  if  not  to  cause  reduction  of  pressure  in  hyper- 
tension, 

(<r)  Fasting  for  a  day  or  marked  restriction  of  food  for  several 
days  may  benefit  plethoric  individuals.  It  is  one 
of  the  surest  means  of  lowering  pressure.  Emacia- 
tion must  be  avoided  because  it  increases  cardiac 
weakness. 

{d)  Relief  from  psychic  strain,  e.g.,  business  cares,  may  be 
followed  by  a  fall  in  pressure. 

{e)  Removal  of  foci  of  infection,  e.g.  drainage  of  pus  by 
extraction  of  teeth,  etc. 

3.  When  toxemia  is  present  reduce  it  by: 
{a)   Purgation  or  diuresis. 

{b)    Restriction  of  food,  and  of  proteid  in  particular. 

{c)    Hot-air  baths  or  hot  soaks  if  cardiac  symptoms  permit. 

4.  If  toxemic  symptoms  persist  after  improvement  in  the  circu- 
lation they  are  probably  uremic  in  origin  and  should  be  treated 
accordingly  (p.  71). 

PULMONARY  EDEMA 
I.  With  Hypertension. 

Note. —  Occurs  commonly  and  characteristically  in  hyper- 
tension. The  attack  generally  follows  exertion  and  may  not 
have  been  preceded  by  marked  symptoms  of  cardiac  insufficiency. 

The  onset  is  sudden  and  alarming. 


By  mouth: 


[33] 

The  symptoms  in  severe  cases  are  marked  dyspnoea,  cyanosis, 
wheezing,  cough,  and  pinkish,  frothy  expectoration.  There  may 
be  precordial  pain. 

Treatment.  Mild  attacks  may  pass  off  after  a  little  rest. 
Severe  attacks  require  energetic  and  prompt  treatment  as  follows: 

1.  Prop  the  patient  up  so  he  can  sit  upright  without  effort. 

2.  Give  morphine  sulphate,  gr.  I  (or  0.016  gm.)  atropine 
sulphate,  gr.  xro  to  wo  (or  0.00065  ^o  o-ooi  g"^-)  ^^'^  nitroglycerin, 
gr.  Tw  to  -it  (or  0.00065  to  o.ooi  gm.)  subcutaneously  at  once. 

3.  Unless  improvement  begins  promptly,  the  nitroglycerin 
should  be  repeated,  and  venesection  may  be  required. 

4.  The  following  drugs  may  be  of  service. 

By  inhalation:  Amyl  nitrite:  5  m.  (or  0.3  c.c). 

Spiritus  ammonise  aromaticus:    i  drach.  (or 

4  c.c). 
Spiritus  setheris  compositus:*    i   drach.   (or 

4  c.c). 
Whiskey  or  brandy:   from  4  drach.  to  i  oz. 

(or  15  to  30  c.c). 

„'  ,        f  Cocaine  hydrochloride:   i  gr.  (or  0.016  gm.); 

bubcutaneousiy:    i  -j        ,      j 

•^       [      said  to  be  dangerous. 

Intravenously:  Strophanthin:  p.  279. 

5.  Do  not  attempt  to  transport  the  patient  until  immediate 
danger  has  passed. 

6.  Rest  in  bed  is  advisable  for  a  few  days  to  allow  the  heart  to 
recover. 

7.  Digitalis,  purgation,  etc.,  may  be  needed. 

8.  Subsequent  regulation  of  life  is  essential  to  avoid  recurrence. 

II.  Without  Hypertension. 

Pulmonary  edema  may  appear  in  cardiac  insufficiency  from  any 
cause.  It  is  common  in  mitral  stenosis,  but  seldom  acute  enough 
to  require  special  treatment.  When  severe  it  should  be  treated 
as  in  hypertension,  except,  that  the  blood-pressure  being  normal 
or  low,  nitrites  are  of  doubtful  value  and  may  perhaps  do  harm. 

Pulmonary  edema  occurs  also  in  infectious  diseases.  In  pneu- 
monia it  may  be  very  acute,  but  is  not  necessarily  of  cardiac  origin. 
For  treatment  see  p.  47. 

*  "Hoffmann's  anodyne." 


[35] 

CIRCULATORY  DISORDERS  OF  INFECTIOUS  FEVERS  AND 

SEPSIS. 

Nofe. —  Before  this  subject  can  be  put  on  a  satisfactory  basis 
more  must  be  learned  about  the  causes  and  nature  of  the  circula- 
tory changes  and  about  the  action  of  drugs  on  the  circulation  in 
infectious  fevers. 

The  subject  will  be  discussed  in  the  light  of  what  seem  to  be 
facts  under  the  following  heads :  — 

yf.   General  Circulatory  Disorders. 

1.  Tachycardia. 

2.  Bounding  pulse. 

3.  Wiry  pulse. 

4.  Dicrotic  pulse. 

5.  Thready  pulse. 

6.  Syncope. 

7.  Circulatory  collapse  or  toxemic  shock. 

8.  Bradycardia  (not  due  to  block). 

B.  Myocardial  Disorders. 

1.  Infection  of  myo,  endo,  or  pericardium. 

2.  Heart-block. 

3.  Malnutrition  of  myocardium.  -" 

C.  Disorders  of  Pulmonar  Circulation. 

{a)  Acute. 
(^)   Insidious, 
(c)   Recurrent. 

(a)  Embolism  of  pulmonary  artery 
or  of  its  large  branches. 

(i?)  Very  extensive  consolidation. 

Note. —  The  conditions  in  Group  A,  above,  are  attributable 
chiefly  to  toxemia  acting  probably  on  the  nervous  system  and  to 
some  extent  on  the  myocardium  and  blood-vessels  as  well. 

Variations,  often  rapid,  in  the  rate  and  character  of  the  pulse 
occurring  entirely  independently  of  treatment  are  very  common. 
They  may  be  most  difficult  of  interpretation  and  may  lead  to  false 
opinions  on  the  effects  of  treatment.  Some  of  the  changes  are 
coincident  with  and  probably  dependent  upon  changes  of  body- 
temperature.  A  certain  degree  of  circulatory  change  is  normal  in 
health. 


I.  Toxic  edema: 


Obstructive  lesions: 
e.g. 


[37] 


1.  Combat  toxemia: 

2.  Conserve  patient's 

strength : 

3.  Avoid     mechanical 

handicaps  to  cir- 
culation : 


5.   Stimulants: 


A.   PROPHYLAXIS  IN  GENERAL. 

To  Ward  off  Serious  Circulatory  Symptoms. 

\d)  Neutralize  toxin  with  antitoxin 
when  practicable. 

{b)  Dilute  toxins. 

(<:)   Promote  their  elimination. 

{a)  Promote  comfort. 

{]?)  Minimize  exertion. 

(c)  Prevent  anxiety. 

{a)  Prevent  abdominal   distention. 

ib)  Recumbent  posture  with  head 
low  is  best  when  comfortable 
for  the  patient. 

{a)  Careful  attention  to  diet  with 
due  regard  to  the  individual 
and  to  circumstances. 

{h)  Free  use  of  alcohol  is  beneficial 
in  some  cases.  It  is  harmful 
in  others.     See  Alcohol,  p.  301. 

id)  An  abundance  of  cool,  fresh 
air  at  all  times  in  the  sick 
room  acts  as  a  tonic. 

ih)  Drugs  should  be  used  only 
when   specially   indicated. 

(<:)  Sponge  baths  are  beneficial  in 
suitable  cases,  see  Typhoid, 
p.  87.  _ 

{a)  Have  saline  or  glucose  solution 
kept  in  readiness. 

ib)  Have  blood  of  patient  typed 
and  know  where  to  get  donor 
if  needed  for  transfusion. 


4.   Maintain  nutrition: 


Prepare  for  emergency 
in  serious  cases: 


SYMPTOMATIC  TREATMENT. 

I.  Tachycardia  or  acceleration,  with  little  change  in  pulse-wave 
or  blood-pressure,  is  usual  with  slight  fever  in  mild  or  early  infec- 
tions. Nervousness  or  anxiety  may  be  a  factor.  Do  not  over- 
look hyperthyroidism. 


[39] 

{a)   Slight  tachycardia  is  unimportant. 

{b)    Tachycardia  of  120  or  over  may  be  followed  by  more 

serious  symptoms.     An  ice-bag  kept  over  the  heart 

seems  to  slow  it  in  some  cases. 

2.  "  Bounding  pulse  ";  wave  large,  rising  and  falling  quickly. 
Pulse  pressure  is  increased  by  rise  of  systolic  or  fall  of  diastolic 
pressure  or  by  both  acting  together. 

This  type  of  pulse  is  usual  in  the  early  stages  of  severe  infections 
with  considerable  fever  and  may  be  followed  by  more  serious 
circulatory  changes  with  a  rapid  fall  in  blood-pressure.  (It  is 
seen  also  in  nervous  states  without  fever.) 

{a)   Avoid  cardiac  depressants  if  the  disease  is  of  a  serious 

nature. 
{b)   An  ice-bag  may  be  tried  to  slow  the  heart. 
{c)    Stimulants  are  contraindicated. 

3.  ''  Wiry  pulse";  wave  small,  vessel  contracted,  systolic  pres- 
sure generally  normal,  sometimes  increased.  This  type  of  pulse 
is  seen  occasionally  in  pneumonia  and  probably  in  other  diseases. 
Graver  circulatory  changes  with  "  thready  pulse  "  or  pulmonary 
edema  may  follow  rapidly. 

{a)   Depressants  are  dangerous. 

{b)  When  the  pulse  rate  exceeds  120  it  may  be  advisable  to 
try  digitalis  in  the  hope  of  forestalling  graver  circu- 
latory changes. 

4.  Dicrotic  pulse  and  the  "  water-hammer  pulse  "  indicate  low 
diastolic  pressure.  The  systolic  pressure  as  a  rule  is  slightly  re- 
duced as  well.  The  circulatory  disturbance  seems  to  be  primarily 
due  to  relaxed  vessels.  The  dicrotic  pulse  is  most  common  in 
typhoid  in  which  disease  it  is  not  a  serious  symptom.  The  water- 
hammer  pulse  in  the  absence  of  valve  lesion  seems  to  indicate  a 
more  severe  grade  of  vascular  relaxation  which  may  be  followed  by 
circulatory  collapse. 

{a)   Rely  mainly  on  general  supportive  measures. 

{b)    Copious  ingestion  of  fluid  is  particularly  important. 

{c)    Keep  the  head  low. 

5.  "  Thready  Pulse,"  small,  weak,  rapid  and  "  running." 
Beats  are  often  unequal  and  sometimes  slightly  irregular.  The 
systolic  pressure  is  much  reduced  and  the  diastolic  pressure  is 


[41] 

generally  lowered  too,  but  the  pulse  pressure  is  small.  This  type 
of  pulse  is  common  in  the  later  stages  of  severe  infections.  Prob- 
ably both  myocardium  and  vessels  are  at  fault.  Circulatory 
collapse  may  follow  gradually  or  rapidly.  Sudden  death  from 
myocardial  weakness  may  ensue. 

(a)  Measures  to  combat  toxemia  are  urgently  required. 
{F)  Copious  ingestion  of  fluid  should  be  insisted  upon  unless 
there  is  pronounced  weakness  of  the  myocardium  or 
pulmonary  edema. 
{c)  When  sufficient  fluid  cannot  be  taken  by  mouth,  salt  or 
glucose  solution  should  be  used  by  rectal  enema 
several  times  daily  or  by  rectal  seepage. 

(d)  In  more  urgent  cases  suitable  solutions  can  be  used  by 

hypodermoclysis  or  intravenously.  About  a  pint 
should  be  given  at  a  time.  When  the  intravenous 
route  is  used  the  fluid  must  be  allowed  to  run  slowly 
and  the  pulse  must  be  carefully  watched  meanwhile. 
If,  after  initial  improvement,  it  loses  force  or  shows  the 
least  irregularity,  stop  the  transfusion  at  once  lest 
cardiac  dilatation  result. 

(e)  Transfusion  with  blood  or  with  preserved  corpuscles  may 

be  expected  to  have  a  more  lasting  eff'ect  than  solutions. 
Do  not  raise  the  patient's  head  higher  than  comfort- 
able breathing  demands  lest  syncope.or  collapse  ensue. 
The  best  position  for  most  cases  is  flat  with  but  one 
thin  pillow  under  the  head. 
(/)  Intravenous  medication  v/ith  stimulants  of  the  digitalis 
group  or  powerful  vaso-constrictors  such  as  adrenalin 
should  be  given  slowly  and  not  more  than  half  the  full 
dose  should  be  used  at  one  time.  It  is  better  to  repeat 
the  dose  in  a  short  time  or  at  intervals  than  to  cause  a 
marked  and  sudden  rise  of  blood-pressure  which  is  apt 
to  be  followed  by  a  disastrous  fall. 

Caffeine,  or  strichnine  may  be  prescribed  for  their 
supposed  tonic  effect.  Neither  is  likely  to  have  much 
direct  action  on  the  pulse. 

Full  doses  of  digitalis  may  be  tried  by  mouth.  It  may 
perhaps  do  good  when  myocardial  weakness  is  an 
important  factor. 


[43] 

6.  Syncope  may  occur  in  fevers  when  blood  pressure  is  low. 
Unless  quickly  relieved  it  may  result  in  death. 

{a)    Prevent  it  by  keeping  the  head  low  when  the  circulation 

is  weak. 
{b)    Relieve  it  by  lowering  the  head  and  by  raising  the  foot  of 

the  bed  moderately. 

7.  Circulatory  Collapse  due  to  "Toxemic  Shock"  may  de- 
velop rapidly  or  gradually  in  severe  febrile  cases  and  in  some  other 
conditions.  The  sequence  of  events  seems  to  be  relaxation  of  the 
blood  vessels,  fall  of  diastolic  pressure,  deficient  return  of  blood  to 
the  heart,  resulting  impaired  coronan.'  circulation,  and  consequent 
secondar}"  cardiac  weakness.  Actual  myocardial  damage  may 
co-exist  sometimes. 

It  is  important  to  distinguish  as  clearly  as  possible  between 
"  toxemic  shock "  and  circulators^  collapse  due  essentially  to 
myocardial  weakness  because  treatment  suitable  for  the  former  is 
likely  to  prove  fatal  to  patients  suffering  from  the  latter  condition. 
The  milder  forms  of  "  shock  "  may  recur  in  severe  cases  of 
t)"phus  fever,  sometimes  in  the  day-time,  more  often  late  at  night. 
Severe  grades  are  seen  in  t\-phus,  in  t;rphoid  and  in  pneumonia. 
Recover}'  is  possible  but  death  the  rule. 

{a)  Remove  pillows  and  raise  foot  of  bed  about  twelve  inches. 
Do  not  lower  it  again  for  hours  or  days  and  then  do  so 
gradually. 
{b)  Administer  something  producing  a  prompt  reflex  vascular 
response,  e.g.  a  drink  of  hot  tea,  or  of  hot  water,  a 
spoonful  of  brandy  or  an  intramuscular  injection  of  a 
locally  irritating  substance  such  as  ether,  alcohol,  or 
perhaps  camphor. 
{c)  To  promote  return  of  blood  to  the  heart,  the  limbs  and 
abdomen  may  be  tightly  bandaged  so  as  to  squeeze  the 
blood  out  of  the  veins.  This  measure  has  proved  yoxy 
effective. 
{d)  Solutions  by  hypodermoclysis  or  intravenously  generally 
cause  marked  and  rapid  improvement  which  may  be 
maintained  for  hours  or  days.  (See  important  facts 
under  "Thready  Pulse,"  5.(d)  above.) 


[45] 

{e)  The  use  of  powerful  stimulants  of  the  digitalis  or  vaso- 
constrictor groups  in  full  doses  intravenously  is  prob- 
ably unwise  lest  a  marked  rise  of  blood-pressure  be 
followed  rapidly  by  a  corresponding  fall.  The  writer 
has  seen  this  happen  repeatedly  with  serious  conse- 
quences. Smaller,  repeated  doses  would  probably  do 
good. 

(/)  The  work  of  Porter,*  on  traumatic  shock  contains  much 
that  may  prove  of  value  in  the  treatment  of  "  toxemic 
shock." 

8.    *'  Simple  "  Bradycardia  (pulse  rate  above  40). 
Common  in  convalescent  stage  of  fevers  and  particularly  in 
typhus  fever.     (In  some  individuals  bradycardia  is  constant  in 
health.) 

{a)   Physical  exertion  should  be  restricted  as  a  precaution  in 

post  febrile  cases. 
{b)   No  other  treatment  is  required. 

B.   TREATMENT  FOR  MYOCARDIAL  DISORDERS. 

1.  Myocardial  infections  require  the  same  general  management 
as  "  Acute  Infectious  Lesions  of  Valves,"  p.  27,  Sect.  II.  See  also 
"  Methods  of  Treatment "  under  "  General  Circulatory  Dis- 
orders," (p.  17). 

Endocardial  and  pericardial  lesions  are  generally  associated 
with  infection  of  the  myocardium.  They  require  the  same  treat- 
ment except  that  pericarditis  may  demand  aspiration  or  surgical 
drainage. 

2.  Heart-block  may  be  due  to  a  myocardial  lesion  directly  affect- 
ing the  bundle  of  His,  to  digitalis  or  to  both  factors  combined  when 
neither  alone  would  produce  it.  In  such  cases  a  small  dose  of 
digitalis  may  induce  block.  Block  is  not  usually  associated  with 
severe  decompensation  but  symptoms  may  be  serious  during  the 
transition  from  sinus  to  nodal  rhythm. 

As  a  rule  drugs  of  the  digitalis  group  should  be  omitted  at  the 
first  sign  of  block. 

Other  treatment  is  symptomatic  as  for  "  General  Circulatory 
Disorders  "  (p.  17). 

*  Boston  Med.  and  Surg.  Jour.,  May  i6,  191 8,  p.  657. 


[47l 

3.  Malnutrition  of  Myocardium  may  cause  serious  circulatory 
weakness  in  the  presence  of  emaciation  or  severe  anemia. 

{a)    Special  attention  should  be  given  to  nutrition. 

{b)  Alcohol  may  be  of  service  as  an  appetizer.  A  glass  of 
sherry  before  meals  with  or  without  bitters  or  con- 
taining a  few  minims  of  tincture  of  Nux  vomica,  a  glass 
of  whiskey  and  water,  or  one  of  beer  with  meals,  if 
palatable  to  the  patient,  may  do  good. 
Other  patients  only  capable  of  taking  liquids  and  in  a 
condition  of  semistarvation  may  sometimes  take  large 
quantities  of  alcohol  with  benefit.  In  such  cases  it 
seems  to  act  as  a  food.     See  Alcohol,  p.  301. 

4.  Sudden  death  in  acute  febrile  conditions,  frequently  attrib- 
uted to  pulmonary  embolism,  seems  more  often  to  be  caused  by 
myocardial  weakness  without  gross  lesion. 

C.   DISORDERS  OF  THE  PULMONARY  CIRCULATION. 
I.   Toxemic  edema. 

{a)   The  Acute  Form  has  two  varieties. 

(i)  An  attack  which  supervenes  at  the  onset  of  pneu- 
monia with  severe  dyspnoea,  cyanosis  and  signs  of 
edema  may  be  due  in  part  to  mechanical  causes.  Vene- 
section and  should  be  performed  and  a  quickly  acting, 
powerful  stimulant  like  strophanthin  0.5  mgm.  intrave- 
nously may  perhaps  do  good. 

A  hypodermic  injection  of  morphine  gr.  i  to  J  (or 
0.01080  to  0.0162  gm.)  with  perhaps  atropine  gr.  xro  to 
-it  (or  0.00065  to  o.ooiio  gm.)  if  given  promptly,  may 
be  sufficient  in  milder  attacks. 

(2)  Acute  edema  coming  in  lobar  pneumonia  after  the 
fifth  day  or  later  is  generally  hopeless,  but  I  have  seen  a 
patient  rally  quickly  from  two  extremely  severe  and 
sudden  attacks  after  receiving  atropine  gr.  ro  (or 
0.00130  gm.)  hypodermically.  He  made  a  good  recovery. 
Venesection  might  have  served  but  would  have  left  the 
patient  weaker.  Strophanthin  might  have  been  tried. 
Morphine  with  the  atropine  may  be  adviantageous  pro- 
vided there  is  edema  alone,  but  when  the  frothy  sputum 
of  edema  is  combined  with  the  thick  secretion  of  bron- 


[49] 

chitis,  morphine  should  be  used  with  caution  lest  by 
stopping  cough  this  secretion,  which  cannot  readily  be 
absorbed,  be  retained  in  the  lungs.  Similar  conditions 
are  seen  in  some  severe  cases  of  typhus  fever  and  pneu- 
monic influenza.  Treatment  as  above  described  may  be 
tried  but  is  not  likely  to  save  the  patient. 
{b)  Insidious  edema  varying  from  slight  "  hypostatic  con- 
gestion "  to  the  most  severe  forms  may  develop  in  various 
infections  after  a  week  or  more  of  high  fever.  It  was 
common  in  the  severe  broncho-pneumonic  cases  of  in- 
fluenza in  the  recent  pandemic. 

(i)  For  "  hypostatic  congestion  "  measures  to  support 
the  circulation  (see  "  Prophylaxis   in  General  "  above) 
and  frequent  change  of  position  are  usually  efficacious, 
(see  under  typhoid,  nursing,  p.  83.) 
(2)  Edema    which    increases    gradually    and    becomes 
severe  in  spite  of  prophylactic  measures,  stimulants  of 
the  digitalis  group,  purgation  and  atropine,  is  probably 
hopeless. 
{c)    Recurrent  edema  has  been  observed  repeatedly  in  typhus 
fever  and  in  infected  penetrating  wounds  of  the  chest 
and  it  probably  occurs  in  other  severe  infections.     It  is 
characterized  by  dyspnoea,  and  white,  frothy  expecto- 
ration developing  rather  gradually  in  the  late  afternoon, 
or  at  night  and  having  a  tendency  to  recur  on  succeeding 
days  at  about  the  same  hour.    The  contents  of  the 
sputum  cup  is  the  key  to  diagnosis  and  treatment. 
There  may  be  an  associated  bronchitis.    When  this  is 
the  case  there  is  mixed  with  the  froth  a  larger  or  smaller 
proportion  of  thick  mucoid  or  muco-purulent  material. 
In  cases  uncomplicated  by  bronchitis  morphine  gr.  i 
(or  0.01080  gm.)  and  atropine  gr.  rio  (or  0.000540 
gm.)  gives  prompt  relief.    When  the  attack  begins  in 
the  afternoon  this  dose  may  need  to  be  repeated  during 
the  night.    When   bronchitis   co-exists  relief  is  less 
marked  and  morphine,  if  repeated,  must  be  used  with 
caution  lest  the  bronchitic  secretion  be  retained. 
1.   Obstructive  Lesions. 

{a)   Very  extensive  pulmonary  consolidation  throws  added 


L5IJ 

strain  on  the  right  ventricle  but  severe  toxemic  is 
generally    associated    with     it.     The    treatment    is 
symptomatic. 
{b)    Pulmonary  embolism,  when  extensive,  is  rapidly  fatal. 
Less  severe  cases  must  be  treated  symptomatically. 

ANGINA  PECTORIS. 

Definition.  Pain  or  distress  attributable  to  spasm,  or  to 
occlusion,  of  a  coronary  artery. 

Spasm  is  generally  associated  with  syphilitic  or  degenerative 
change  in  the  vessel-wall,  but  lesions  may  be  confined  to  other 
parts  of  the  heart  or  to  the  aorta,  and  "  neurotic  angina,"  in  which 
there  is  no  known  lesion,  is  rather  common.  Occlusion  may  be 
thrombotic  or  embolic. 

Angina  may  be  indicative  of  beginning  cardiac  exhaustion  or 
of  deficient  blood-supply  to  the  myocardium. 

Etiological  Classification  of  Angina  Pectoris. 

1 .  Syphilitic :    common  in  men  of  early  middle  age. 

2.  Degenerative  or  arteriosclerotic:  common  in  old  men. 

3.  Embolic:  seen  in  endocarditis  or  intracardiac    thrombosis. 

4.  Neurotic:  common  in  young  women. 

DIAGNOSIS. 

An  accurate  history  of  the  mode  of  onset,  duration  and  radia- 
tion of  the  pain  and  the  discovery  of  an  adequate  background  for 
the  disease  is  of  the  greatest  importance.  Pain  on  exertion 
suggests  angina.  Angina  in  a  young  or  middle-aged  man  suggests 
syphilis. 

A  complete  physical  examination  may  show  nothing  important. 

Angina  in  a  young  woman  suggests  psychic  trauma. 

Painless  angina,  otherwise  typical,  is  seen  rarely. 

I.    SYPHILITIC  ANGINA. 

Pathology.  Syphilitic  changes  in  the  aorta,  aortic  valves  or 
coronary  arteries,  diminishing  their  circulation  are  generally 
present. 

Etiology.  A  late  manifestation  of  syphilis;  commonest  in 
middle  life. 

Prognosis.    The  prognosis  is  very  uncertain. 


[53] 

A.  TREATMENT  IN  GENERAL. 

1.  Antisyphilitic  measures.* 

2.  Regulation  of  life  to  reduce  demands  on  the  heart  to  what 
it  can  meet  is  of  the  utmost  importance. 

id)   Avoid  anything  known  to  bring  on  angina  in  the  indi- 
vidual, e.g.^  exercise  after  meals. 
{]y)    Avoid  physical  and  mental  strain, 
{c)    Avoid  distention  of  the  stomach  and  bowels. 
id)   Food  and  liquids  should  be  taken  in  moderation. 
{e)    Tobacco  and  alcohol  in  great  moderation  if  at  all. 
(/)    Bowels  should  be  kept  free. 
"  3.   Cardiac  insufficiency,  if  present,  requires  appropriate  treat- 
ment on  general  principles. 

4.  Small  doses  of  digitalis  often  help  to  reduce  the  number 
of  attacks  even  when  the  usual  signs  of  cardiac  insufficiency  are 
absent.  Theobromine  sodio-salicylate,  grs.  5  t.i.d.,  or  barium 
chloride,  grs.  to  t.i.d.,  may  be  tried  for  the  same  purpose. 

5.  At  the  first  sign  of  an  attack  the  patient  should  take  nitro- 
glycerin (p.  281)  or  amyl  nitrite,  repeat  it  in  a  few  minutes  if  not 
relieved  and  remain  quiet  for  a  time  after  the  attack  has  passed. 
An  expected  attack  can  sometimes  be  prevented  by  timely  use 
of  nitroglycerin.  The  drug  must  be  always  accessible  without 
effort.  Nitroglycerin  should  be  chewed  and  absorbed  in  the 
mouth  and  amyl  nitrite  taken  by  inhaling  it  from  a  handkerchief. 
It  is  important  to  provide  pearls  which  break  easily  but  not 
spontaneously  if  amyl  nitrite  is  to  be  used. 

B.   TREATMENT  OF  ANGINAL  ATTACKS. 

If  called  to  treat  an  attack  of  angina  use  nitroglycerin  sub- 
cutaneously  or  amyl  nitrite  or  both  immediately.  Repeat  the 
dose  in  a  few  minutes  if  the  patient  is  not  relieved.  If  nitro- 
glycerin gives  no  effect  in  repeated  doses  dsccA  nitrite  may  per- 
haps relieve.  If  the  pain  is  unusually  severe  and  obstinate 
morphine  should  be  injected. 

Do  not  attempt  to  transport  the  patient  and  do  not  allow  him 
to  make  the  slightest  exertion  for  a  time  after  the  symptoms  have 
passed.     Rest  in  bed  is  advisable  after  a  severe  attack. 

*  Arsphenamine  should  not  be  used  in  the  presence  of  severe  cardiac  decompensation. 


Iss] 

n.  DEGENERATIVE  ANGINA. 

Pathology.  Coronary  sclerosis  and  chronic  myocardial  degen- 
eration, with  or  without  fibrous  myocarditis,  will  often  be  demon- 
strable as  part  of  a  v»ddespread  arteriosclerosis. 

Prognosis.  Years  of  life  may  be  possible  but  sudden  death 
may  occur  at  any  time. 

Treatment,     i.   Regulate  life  to  avoid  strain. 

2.  When  there  is  any  cardiac  insufficiency  the  patient  should 
take  digitalis  and  salts  for  long  periods.  The  dose  required  for 
the  individual  must  be  determined  carefully  by  trial. 

3.  Digitalis,  theobromine,  potassium  iodide  or  barium  chloride 
in  small  doses  may  limit  the  number  of  attacks  or  even  prevent 
them. 

4.  If  an  old  syphilis  be  suspected  give  potassium  iodide  and 
protiodide  of  mercury  in  moderate  doses. 

5.  The  treatment  for  the  attack  is  the  same  as  in  syphilitic 
angina. 

III.  EMBOLIC  ANGINA. 

Vaso-dilators  are  likely  to  give  little  relief.  Morphine  is  usually 
required  in  large  doses.  Death  may  come  suddenly  at  onset  of 
symptoms. 

IV.  NEUROTIC  ANGINA. 

Pathology.    No  characteristic  changes  recognized. 

Etiology.  Commonly  due  to  excess  in  tea,  coffee,  or  tobacco,  to 
fear  or  emotional  shock  and  often  associated  with  debility.  It  is 
seen,  almost  exclusively,  in  neurotic  young  women. 

Prognosis.  Death  is  not  to  be  expected  and  the  chance  of 
complete  cure  is  excellent. 

Treatment,     i .   Remove  the  cause  when  possible. 

2.   General  hygienic  measures. 

By  these  means  recurrence  can  be  prevented. 

The  attack  is  generally  too  brief  and  mild  to  require  treatment, 
but  when  severe,  it  should  be  treated  like  organic  angina. 

No^e. —  Cardio-spasm  may  simulate  angina  pectoris. 


[57] 

CHAPTER  II. 
NEPHRITIS. 

CLASSIFICATION. 

1.  Acute  Renal  Irritation. 

2.  Acute  Nephritis. 

3.  Chronic  Nephritis. 

4.  SyphiHtic  Nephritis. 

5.  Arteriosclerotic  Degeneration. 

6.  Passive  Congestion. 

PATHOLOGY  AND  DIAGNOSIS. 

This  classification  aims  to  separate  only  the  more  important 
types  of  nephritis  which  can  be  recognized  clinically  and  which 
require  different  treatment. 

Acute  renal  irritation  is  to  be  expected  in  the  presence  of  acute 
general  infections  with  high  fever.  It  is  not  a  true  nephritis  and  it 
has  no  important  significance.  Cloudy  swelling  of  the  kidneys  is 
probably  associated  with  it. 

Glomerulo-nephritis,  acute,  subacute,  or  chronic  results,  as  a 
rule,  from  infection  with  the  streptococcus  viridans  and  this  type 
of  nephritis  includes  the  great  majority  of  all  cases  of  true  nephritis. 
Recovery  may  take  place  after  the  acute  stage  or  the  disease  may 
become  chronic  and  incurable.  The  stages  and  phases  are  as 
follows: 


Stages 


Acute  D7        J  Latent 

c,  1  rhases\    .     . 

subacute  [  Active 


Chronic 

Any  stage  may  be  without  symptoms.  The  urine  in  the  early 
acute  stage  may  be  negative.  In  chronic  cases  there  is  no  al- 
bumen and  little  sediment  at  times,  but  the  specific  gravity  is 
constantly  low. 

In  adults,  active  phases  of  the  subacute  stage  are  frequently 
mistaken  for  acute  nephritis. 

Left-ventricular  hypertrophy  and  hypertension  develop  gradu- 
ally and  there  is  a  progressive  fall  in  specific  gravity  associated 
with  an  increase  in  amount  of  urine. 


[59] 

The  last  stage  shows  marked  left  ventricular  hypertrophy,  a 
blood-pressure  generally  over  200  mm.  of  mercury  and  a  urine  of 
very  low  gravity,  containing  little  or  no  albumen  and  a  scanty 
sediment.  At  this  stage  many  of  the  glomeruli  and  much  of  the 
parenchyma  has  been  replaced  by  connective  tissue,  and  shrinkage 
has  followed  so  that  the  kidneys  are  much  diminished  in  size. 
The  chief  dangers  are  from  uremia  or  from  cardiac  insufficiency 
secondary  to  hypertension.  In  the  absence  of  arteriosclerosis  a 
provisional  diagnosis  of  chronic  nephritis  may  often  be  made  by 
the  evidence  of  hypertension  and  of  cardiac  hypertrophy.  Cases 
of  chronic  nephritis  complicated  with  arteriosclerosis  are  liable  to 
apoplexy. 

Syphilitic  Nephritis  is  generally  regarded  as  an  unusual  form  of 
acute  nephritis.  It  occurs,  according  to  Osier,  most  commonly 
in  the  secondary  stage  of  syphilis  within  six  months  of  the  primary 
lesion  and  it  resembles  glomerular  nephritis.  Gumma  of  the 
kidney  is  rarely  seen  but  it  is  probable  that  some  instances  of  renal 
arteriosclerosis  are  of  syphilitic  origin.  Signs  of  an  active  syphilis 
in  the  presence  of  a  nephritis  suggest  but  do  not  prove  that  the 
two  are  related.  The  blood-pressure  is  not  usually  much  in- 
creased. 

Arteriosclerotic  Degeneration  of  the  kidney  is  most  common  in 
old  age.  It  may  be  part  of  a  widespread  arteriosclerosis  or  it  may 
be  manifested  chiefl)^  in  the  kidney.  There  occurs  a  non-inflam- 
matory destruction  of  parts  of  the  kidney  dependent  on  sclerosis 
of  the  arteries  supplying  those  parts.  Local  shrinkage  and  irregu- 
larity or  roughness  of  the  surface  results. 

The  urine,  at  first,  may  show  considerable  albumen  and  some 
blood  and  casts.  Later  it  resembles  that  of  chronic  nephritis. 
Hypertension  and  left  ventricular  hypertrophy  are  generally 
well  marked  in  the  later  stages  of  renal  degeneration. 

The  greatest  dangers  are  from  cardiac  insufficiency  or  cerebral 
hemorrhage.  Typical  uremia  occurs  rarely  if  at  all  in  pure 
degenerative  cases  but  there  is  often  more  or  less  chronic  nephritis 
combined  with  the  degenerative  lesions.  Chronic  lead-poisoning, 
gout  or  syphilis  may  be  important  etiologically. 

Passive  Congestion  is  secondary  to  congestion  in  the  venous 
circulation.  Therefore,  it  is  commonly  symptomatic  of  cardiac 
insufficiency.    The  urine  is  high  colored,  scanty  and  of  a  high 


[6i] 

gravity.  Albumen  and  casts  are  found,  varying  in  amount  and 
number.  There  are  no  uremic  symptoms,  and  the  urine  clears 
rapidly  after  removal  of  the  congestion. 

Passive  congestion  may  mask  an  acute  nephritis,  especially 
in  the  active  stage  of  endocarditis. 

Mixed  lesions  are  very  common  and  glomerulo-nephritis  is 
often  combined  with  arterio-sclerotic  degeneration.  Either  pro- 
cess may  predominate. 

Less  common  lesions.  The  form  of  acute  nephritis  produced 
by  irritant  poisons  such  as  corrosive  sublimate  is  of  the  tubular 
variety. 

A  form  of  chronic  nephritis  with  hypertension  may  result  from 
lead-poisoning. 

In  chronic  suppurative  conditions,  particularly  when  related  to 
tuberculosis  or  syphilis,  amyloid  degeneration  of  the  kidney  may 
develop. 

There  are  other  unusual  or  atypical  renal  degenerations  or 
nephritides  difficult  to  classify. 

ACUTE  RENAL  IRRITATION. 

Treatment.  The  signs  of  irritation  can  be  much  reduced  by 
the  free  administration  of  water.  The  water  dilutes  the  irritating 
substance  and  promotes  excretion  by  stimulating  diuresis.  No 
other  direct  treatment  is  needed. 

Caution.  Before  discharging  the  patient  look  for  evidence  of 
nephritis. 

ACUTE  NEPHRITIS. 

PRINCIPLES  OF  TREATMENT. 

A.  Reduce  the  demands  on  the  kidney  by: 

1.  Rest  in  bed. 

2.  Elimination  by  other  channels.  ]  „     ^  . 

\  bweatmg. 

3.  Suitable  diet. 

4.  Limitation  of  liquids  in  suitable  cases. 

B.  Maintain  nutrition. 

C.  Avoid  exposure  to  cold  or  to  sudden  cooling. 

D.  Drugs  should  be  used  only  when  indicated;  never  by  routine. 


[^3] 

METHODS  OF  TREATMENT. 

Sweating,     i.  Hot-air  bath  in  bed  or  chair. 

2.  Hot  tub-bath. 

3.  Hot  wet  pack. 

4.  Electric  hght  bath. 

5.  Turkish  or  Russian  bath. 

Hot-air  baths  are  best  given  in  bed.  If  the  baths  cause  profuse 
sweating  they  may  be  used  daily  for  an  hour  or  more.  If  sweating 
does  not  begin  promptly  a  drink,  hot  or  cold,  may  start  it,  or 
pilocarpine  (gr.  i  or  0.01080  gm.)  may  be  administered  sub- 
cutaneously.  Pilocarpine  may  cause  pulmonary  edema  and  is, 
therefore,  contraindicated  when  the  heart  is  weak,  the  lungs  con,- 
gested,  or  the  patient  unconscious.  Some  patients  who  sweat 
little  at  first  respond  well  to  subsequent  baths. 

If  sweating  cannot  be  induced,  if  the  pulse  becomes  weak,  or  if 
the  patient  develops  cardiac  symptoms  during  a  bath  the  baths 
must  be  given  up.  They  should  not  be  ordered  for  an  uncon- 
scious patient  without  consideration  followed  by  close  observation. 

Hospitals  provide  apparatus  for  the  hot-air  bath.  In  private 
houses  it  can  be  improvised  with  barrel-hoops  or  strong  wire  to 
arch  the  bed,  an  oilcloth  from  the  kitchen  table  as  a  rubber  sheet, 
an  elbow  of  stovepipe  and  a  kerosene  lamp  to  provide  the  heat;  or 
the  patient,  without  clothing,  may  sit  in  a  cane-bottomed  chair 
under  which  stands  a  small  lamp.  Blankets  are  then  wrapped 
around  the  chair  and  the  patient  together,  leaving  no  hole  for  the 
heat  to  escape. 

Care  must  be  taken  not  to  set  the  blankets  on  fire. 

The  value  of  sweating  for  nephritics  has  been  questioned.  In 
non-uremic  cases  with  edema,  I  believe  that  it  often  promotes 
diuresis. 

Purgation.  Obtain  watery  catharsis  to  reduce  edema  and  to 
increase  elimination  of  toxic  material  by  the  intestinal  tract. 
Magnesium  sulphate,  or  compound  jalap  powder  with  additional 
potassium  bitartrate,  or  elaterium  are  good  for  this  purpose 
(p.  283). 

In  the  absence  of  edema,  purgation  should  not  be  excessive, 
lest  the  patient's  nutrition  suffer. 


[65] 

Diet.  Proteids,  meat  broths,  spices,  acids  and  alcohol  irritate 
the  kidney  and  are  to  be  avoided  during  the  acute  stage. 

Milk  is  an  exception  to  the  rule  against  proteid  because  experi- 
ence shows  that  it  is  not  injurious.  A  diet  exclusively  of  milk 
becomes  monotonous  if  long  continued  and  such  large  quantities 
are  needed  to  maintain  nutrition  that  the  fluid  part  may  tend  to 
increase  edema.* 

Salt  seems  not  to  be  harmful  as  a  rule.  When,  however,  edema 
persists  in  spite  of  other  treatment,  a  "  salt-free  "  diet  may  be 
tried,  i.e.,  salt  is  not  to  be  added  to  food  either  before  or  after 
cooking.  This  change  is  followed  occasionally  by  rapid  disap- 
pearance of  the  edema.  If  deemed  advisable  the  phosphate  in 
milk  can  be  precipitated  by  adding  5  grs.  (or  0.3  gm.)  of  calcium 
carbonate  per  pint  of  milk. 

Diet  List  (incomplete).  Milk,  cream,  butter,  sugar,  junket, 
ice  cream,  bread,  toast,  cereals,  rice,  potato,  macaroni,  sago, 
tapioca,  spinach,  lettuce,  sweet  raw  fruits  or  stewed  fruits. 

In  convalescence  enlarge  diet  cautiously  on  account  of  danger 
of  relapse.  When  returning  to  proteid  foods  allow  eggs  first,  then 
fish  and  lastly  meat,  red  or  white. 

Liquids,  including  liquid  foods,  should  be  limited  strictly  when 
there  is  anasarca  or  when  they  are  not  being  fully  excreted.  One 
pint  in  twenty-four  hours  may  be  enough.  Cracked  ice  may  be 
used  for  thirst,  but,  if  the  patient  suffers,  more  liquid  should  be 
allowed. 

Water  is  an  excellent  diuretic  wheh  freely  excreted.  It  dilutes 
irritating  substances  and  favors  their  elimination. 

Nutrition.  The  quantity  of  food  to  be  prescribed  depends  on 
the  severity  of  the  nephritis,  the  physical  strength,  and  the  state 
of  nutrition  of  the  patient.  Strong,  well-nourished  patients  having 
severe  nephritis  may  benefit  by  fasting  for  a  day  followed  by  very 
small  quantities  of  food  for  several  days.  A  feeble,  emaciated  and 
anemic  person  should  receive  food  enough  to  maintain  body- 
weight. 

Exposure.  To  prevent  chill,  keep  room  at  equable  temperature 
and  let  patient  wear  flannel  or  lie  between  blankets. 

Medication.  Irritating  diuretics,  such  as  calomel,  are  danger- 
ous in  all  forms  of  nephritis. 

*  Three  quarts  of  milk  furnish  about  2000  calories  which  is  scant  for  an  adult. 


Theobromine;,  theophylline  and  apocynum  are  useless  and  may 
perhaps  do  harm  in  acute  nephritis. 

Mild  sahne  diuretics  or  alkaline  mineral  waters  may  be  valuable, 
particularly  in  convalescence,  but  it  may,  perhaps,  be  wiser  to 
avoid  them  in  severe  cases  during  the  early  stage. 

For  anemia,  iron  may  be  tried,  e.g.^  "  Blaud's  Pill,"  or  "  Bash- 
am's  Mixture  "  (Liquor  ferri  et  ammonii  acetatis  U.  S.)  which 
contains  iron  and  acts  also  as  a  mild  diuretic. 

Prophylaxis.  If  it  appears  that  the  tonsils  were  the  point  of 
entrance  or  the  original  seat  of  disease  their  removal  at  a  suitable 
time  should  be  advised. 

Uremia.  For  treatment  see  p.  71. 

CHRONIC  NEPHRITIS. 
PRINCIPLES  OF  TREATMENT. 

1.  Adequate  nourishment  is  essential  because  the  disease  is 
chronic  and  a  cure  not  to  be  expected. 

2.  Limit  demands  on  the  kidney  and  guard  against  uremia  by 
(a)  diet,  {i^)  elimination. 

3.  Guard  against  cardiac  insufficiency  by  avoiding  physical 
and  mental  strain. 

4.  Avoid  exposure  to  cold. 

METHODS. 

Methods  are  the  same  in  general  as  for  acute  nephritis,  but 
they  must  be  applied  with  regard  to  the  condition  of  the  patient 
and  the  stage  and  severity  of  the  disease. 

Avoid  unnecessary  restrictions.  A  too  monotonous  diet  leads  to 
malnutrition. 

The  Active  Phase  may  be  treated  as  acute  nephritis  for  a  short 
time  or  when  there  is  doubt  of  the  diagnosis,  but  chronic  cases 
should  be  treated  as  such  as  soon  as  possible  because  adequate 
nutrition  is  important  for  them  and  their  diet  should  be  more 
liberal. 

Latent  phase:   subacute,  or  chronic: 

I.   Restrict  more  or  less  the  following: 
(a)   Meats.  (d)   Alcohol. 

(^)    Meat  broths.  (e)    Acids. 

{c)    Spices.  if)    Salt. 


[69] 

2.  To  favor  elimination  of  toxic  material  the  following  may  be 
advised : 

[a)   A  saline  cathartic  every  second,  third,  or  fourth  day. 

Bowels  must  be  kept  free. 
ih)   Hot  tub-baths,  Russian,  or  Turkish  baths,  once  or  twice 

weekly. 
{c)    Alkaline  mineral  waters  with  meals. 

3.  Uremia.     For  treatment  see  p.  71. 

4.  Cardiac  Insufiiciency  demands  prompt  recognition  and 
treatment.     It  results  commonly  from  hypertension,  p.  29. 

SYPHILITIC  NEPHRITIS. 

I.  Apply  principles  advised  for  acute  or  chronic  nephritis 
according  to  the  severity  and  symptoms  of  the  case. 

1.  Iodide  and  mercury  or  salvarsan  should  be  used  in  small 
doses. 

3.  Watch  urine  and  omit  mercury  if  renal  irritation  increases 
under  treatment.  When  the  diagnosis  is  correct  the  urine  gener- 
ally improves  promptly.  As  there  are  no  characteristic  signs 
mistakes  of  diagnosis  easily  occur. 

ARTERIOSCLEROTIC  RENAL  DEGENERATION. 

TREATMENT. 

1.  Search  for  a  cause  of  arteriosclerosis.  If  such  can  be  found 
and  if  it  is  believed  still  to  be  operative  treat  it  appropriately. 

Such  causes  are,  e.g.^  {a)  chronic  lead-poisoning;  {b)  gout; 
{c)  syphihs;   {d)  prolonged  tension  of  responsibihty. 

2.  Nutrition  must  be  maintained. 

3.  Limit  the  demands  on  the  kidney  by  moderate  restriction  of: 
{a)   Meats.  {d)  Alcohol. 

{h)    Meat  broths.  {e)    Acids. 

{c)    Spices. 

4.  Avoid  physical  and  mental  strain  to  guard  against  {a)  cardiac 
insufficiency;   {}?)  cerebral  hemorrhage. 

5.  Cardiac  insufficiency,  when  present,  should  be  treated  with 
reference  to  its  probable  cause,  e.g.: 

{a)   Degenerative  valve  lesion,  p.  29. 

{]?)    Degenerative  myocardial  lesion,  p.  55. 

{c)   Hypertension,  p.  29. 


[71] 

6.  Mild  toxemia  may  clear  up  under  cardiac  treatment  if  the 
heart  is  at  fault. 
Alkaline  diuretics  may  be  of  use. 
Methods  advised  for  uremia  may  be  used  if  toxemia  be  severe. 

PASSIVE  CONGESTION  OF  THE  KIDNEY. 

The  treatment  is  that  of  the  cause  of  the  stasis. 

UREMIA. 

Note. —  .Uremia  is  an  intoxication  of  unknown  nature,  common 
in  severe  acute  nephritis  and  in  chronic  nephritis,  and  particularly 
so  in  exacerbations  of  the  subacute  stage  of  chronic  nephritis. 

Symptoms  vary  much  in  degree.  There  may  be  mental  sluggish- 
ness, drowsiness  or  coma,  loss  of  appetite,  nausea  or  vomiting, 
muscular  twitchings  or  convulsions,  headache,  delirium,  disturb- 
ance of  vision,  transient  ocular  paralysis,  paresis  of  the  extremi- 
ties or  paroxysmal  dyspnea.  The  urine  is  usually  scanty  or 
suppressed.  Retinitis  and  Cheyne-Stokes  respiration  are  com- 
mon. The  onset  may  be  gradual,  and  with  slight  signs,  or  rela- 
tively acute  and  severe.     Edema  may  be  present  or  absent. 

METHODS  OF  TREATMENT. 
For  mild  uremia: 

I.   Diet  as  for  mild  acute  nephritis. 
1.   Eliminative  measures. 
{a)   Purgation. 
iU)    Sweating. 

ic)    Water  if  there  is  little  or  no  edema. 
id)   Saline  diuretics. 
3.   Cardiac  stimulation  is  essential  if  there  is  any  insufficiency. 
Severe  uremia: 

I.  Diet  should  be  much  restricted  in  quantity  and  quaUty  as 
for  severe  acute  nephritis.  Vomiting  or  unconsciousness  may 
prevent  feeding  for  a  time. 

1.  Water  should  be  administered  freely  unless  there  be  much 
edema.  If  water  cannot  be  taken  by  mouth  it  can  be  used  as 
salt-solution  by: 

(i)   Hypodermoclysis. 

(2)  Intravenously. 

(3)  By  rectum,  {a)  Enema. 

{]?)  Seepage. 


[73] 

3-  Purgation.  Magnesium  sulphate,  or  other  purgatives  (p. 
283)  may  be  used.  Croton  oil  is  useful  especially  for  unconscious 
patients.  If  rubbed  up  with  a  little  butter,  made  into  a  ball  and 
placed  on  the  back  of  the  tongue,  it  will  be  swallowed.  Repeated 
doses  of  purgatives  should  be  employed,  if  needed,  to  obtain 
prompt  and  profuse  watery  catharsis,  but  when  there  is  no  edema, 
excessive  purgation  may  tend  to  concentrate  toxins,  and  may  thus 
do  harm,  unless  counteracted  by  free  administration  of  water. 

4.  Sweating  seems  in  many  cases  to  promote  diuresis  and  to 
reduce  toxemic  symptoms.  Unless  the  patient  is  edematous, 
fluid  withdrawn  should  be  replaced  by  fluid  ingested  lest  toxic 
substances  become  concentrated  in  the  blood.  Hot-air  baths 
may  be  used  daily  if  they  cause  profuse  sweating.  They  should  not 
be  ordered  for  an  unconscious  patient.  Pilocarpine  should  not  be 
used  if  there  is  pulmonary  edema,  cardiac  insufficiency  or  uncon- 
sciousness. 

5.  Venesection.  A  pint  or  more  of  blood  may  be  withdrawn 
from  a  vein  at  the  elbow  by  incision,  or,  if  a  suitable  apparatus  be 
at  hand,  by  aspiration. 

Opinion  is  divided  as  to  the  need  or  value  of  injecting  salt 
solution  after  bleeding.    Ordinarily,  patients  do  well  without  it. 

6.  Colon  irrigations  with  large  quantities  of  hot  water  may  be 
tried  in  the  hope  of  promoting  elimination  of  toxins. 

7.  Drugs.  The  use  of  nitroglycerin  or  other  vaso-dilators  is 
followed  frequently  by  pronounced  diuresis  in  patients  having 
hypertension.    The  eff^ect  is  transient. 

Morphine  may  be  given  subcutaneously  for  convulsions. 

Saline  diuretics,  e.g.,  "  Cream  of  tartar  water,"  *  Pot.  citrate, 
or  "  Basham's  mixture,"  may  be  of  use  when  the  severe  symptoms 
have  subsided. 

Heart  stimulants  are  required  when  there  is  any  cardiac  insuffi- 
ciency, p.  19. 

*  A  sat.  sol.  of  Pot.  bitartrate,  the  strength  of  which  is  i  in  201,  equal  to  about  40  grs. 
in  a  pint,  or  to  3  gm.  in  500  c.c.  of  water.  Lemon  juice  or  lemon  peel  can  be  used  for 
flavoring. 


[75] 

CHAPTER  III. 
ACUTE  INFECTIOUS  DISEASES. 


Rest  in  bed    ,   ;    ^       j  ^  u  t 

b.   io  reduce  metabolic  waste. 


Good  nursing;' 


PRINCIPLES  OF  TREATMENT  FOR  INFECTIOUS  DISSEASES. 

a.  To  conserve  strength. 

ICi 

T  •        r        1        ^      [  a.  "Xq)  dilute  toxins. 

2.  Ingestion  or  much  water  \  .  ..... 

\o.   io  lavor  their  ehmination, 

I  a.  To  favor  digestion. 

3.  Bowels  should  be  kept  clear  i  b.  To  prevent  absorption  of 

I  toxic  substances. 

a.  To  secure  cleanliness. 

b.  To  conserve  strength. 

c.  To  promote  comfort. 

d.  To  afford  accurate  information  to  physi- 
cian. 

e.  To  facilitate  treatment. 

a.  Easy  to  swallow. 

b.  Easily  digestible. 

c.  Nutritious  but  not  bulky. 

d.  Palatable  and  varied. 

I  a.  Frequent  and  small  to  favor  digestion. 

6.  Meals  should  be]  b.  Commensurate  in  quantity  with  diges- 

I  tive  power. 

7.  The  sick-room  should  be  well  ventilated. 

8.  Infection  of  others  must  be  prevented. 

9.  Symptoms  should  be  treated  as  they  arise  with  regard  to 
the  circumstances  of  the  case. 

TYPHOID  FEVER. 

Notes. —  Typhoid  is  characterized  pathologically  by  peculiar 
ulceration  of  the  small  intestines.  Ulceration  is  less  frequent 
in  the  colon  and  is  rare  in  the  rectum. 

Typhoid  bacilli  enter  the  blood,  the  organs,  the  secretions,  and 
the  excretions. 


5.   Diet  should  be 


177J 

The  disease  is  self-limited,  lasting  from  two  weeks  to  three 
months.  Relapses  are  common  and  complications  frequent. 
Toxemia  is  often  severe. 

PROPHYLAXIS. 

Inoculation  with  typhoid  vaccine  (p.  299)  should  be  required  for 
all  hospital  nurses  or  others  who  may  have  the  care  of  enteric 
cases. 

Inoculation  should  be  advised  for  travellers  and  others  who 
cannot  be  certain  of  the  purity  of  water,  milk,  etc.,  which  they  may 
consume. 

COMMON  CAUSES  OF  DEATH. 

1.  Toxemia. 

2.  Exhaustion. 

3.  Severe  complications. 

id)   Perforative  peritonitis. 
{¥)   Repeated  hemorrhages. 

PRINCIPLES  OF  TREATMENT  FOR  TYPHOID. 

A.  Prevent  infection  of  others. 

B.  Dilute  toxins  and  favor  their  elimination. 
C    Conserve  strength  of  the  patient. 

D.  Diet  should  be  suited  to  the  individual  as  well  as  to  the 
disease. 

R.  Drugs  are  to  be  prescribed  for  definite  reasons  only  and  not 
to  reduce  the  fever. 

F .  Observe  the  patient's  condition  closely  and  modify  treat- 
ment promptly  when  indicated. 

G.  Have  the  best  nursing  available  and  if  possible  have  a 
day-nurse  and  a  night-nurse. 

H.  Treat  symptoms  and  complications  with  due  regard  to 
other  circumstances  of  the  case. 

METHODS  OF  TREATMENT  FOR  TYPHOID. 

A.    *'  Enteric  precautions." 

I.   Isolation  of  the  patient  is  desirable. 
1.  Flies  must  be  excluded. 

3.  Those  who  touch  the  patient  should  wash  their  hands 
promptly. 


[79] 

4-  Eating  utensils  should  be  reserved  exclusively  for  the  patient 
and  washed  and  kept  apart. 

5.  Sheets  and  other  linen  when  removed  from  the  sick  room 
should  be  soaked  in  5  per  cent  carbolic  acid  for  at  least  half  an  hour, 
or  boiled. 

6.  The  best  method  of  dealing  with  feces  *  is  that  of  Kaiser. 

"It  consists  of  adding  enough  hot  water  to  cover  the  stool  in 
the  receptacle  and  then  adding  about  j  of  the  entire  bulk  of 
quicklime  (calcium  oxide),  covering  the  receptacle  and  allowing 
it  to  stand  for  two  hours." 

Urine  can  be  treated  similarly  by  adding  enough  quicklime  to 
bring  it  to  a  boil. 

7.  Bath  water  may  be  boiled  after  using  when  practicable,  but 
this  is  not  worth  while  where  plumbing  is  good. 

8.  Cleanliness  of  the  attendant  is  essential. 

B.  Dilution  and  Elimination  of  Toxins. 

1.  The  urinary  output  should  be  kept  above  60  oz.  (nearly  two 
litres)  in  24  hours  by  free  administration  of  water.  A  much  larger 
quantity  of  urine  can  be  obtained  but  it  is  a  question  whether 
water  taken  in  very  large  quantities  may  not  favor  hemorrhage. 
Liquids,  including  liquid  foods,  should  total  about  three  quarts 
daily. 

2.  The  bowels  should  be  kept  clear.  If  they  do  not  move 
freely  suds  enemata  may  be  employed  as  often  as  necessary. 
Cathartics  are  to  be  avoided  as  a  rule  during  the  ulcerative  stage 
because  excessive  peristalsis  may  favor  hemorrhage  or  perforation. 

C.  Conservation  of  Strength.    Very  important  because  of  the 
long  average  duration  of  typhoid. 

1.  The  nurse  should  feed  the  patient,  turn  him  over,  allow  him 
to  do  nothing  for  himself  and  should  make  him  comfortable. 

2.  The  maximum  of  nutrition  should  be  maintained  by  fre- 
quent feedings. 

3.  Visitors  should  be  excluded  entirely  as  a  rule. 

D.  Diet.  Dr.  Shattuck's  principle  in  choosing  a  diet  has  been 
stated  by  him  as  follows:  "  Feed  with  reference  to  digestive  power 

*  H.  Linenthal:  Monthly  Bui.  Mass.  State  Board  of  Health,  Jan.,  1914. 


[8i] 

rather  than  name  of  disease,  avoiding  such  articles  of  diet  as  might 
irritate  ulcerated  surfaces." 

Reqmrements. 

I.   Nutritious  but  not  bulky. 

1.   Easily  digestible. 

3.  Non-irritating  to  intestine. 

4.  Quantity  commensurate  to  digestive  power. 

5.  Adapted  to  the  patient's  condition. 

6.  Palatable  and  varied. 

Meals  should  be  frequent,  at  least  once  in  four  hours.  If  the 
patient  can  take  little  at  a  time  he  should  be  fed  every  two  hours 
or  even  every  hour. 

Diet  List.  An  enteric  diet  may  include  the  following  foods  and 
any  others  that  conform  to  the  requirements  stated  above: 
liquid  foods,  strained  cereals,  custard,  blancmange,  junket,  simple 
ice  cream,  soaked  toast  without  the  crust,  bread  or  crackers  in 
milk,  soft  eggs,  oysters  without  the  heel,  finely  minced  chicken,  etc. 

Coleman  has  shown  that,  by  the  free  use  of  milk-sugar  and  of 
cream,  loss  of  weight  in  typhoid  may  sometimes  be  prevented. 
The  cream  can  be  added  to  milk  or  to  other  foods.  Milk-sugar 
can  be  added  to  liquids,  in  the  proportion  of  |  oz.  in  4  oz.  (or  1 5 
in  120  mils  of  liquid.  Coleman's  diet,  if  used  indiscriminately, 
may  perhaps  cause  death. 

Departure  from  routine  diet  may  be  required  for  various  reasons, 
e.g. 

1.  Patient  too  weak  to  swallow  solid  food. 

2.  Vomiting. 

3.  Persistent  diarrhea,  often  due  to  milk. 

4.  Severe  distension,  often  due  to  milk. 

Advantages  of  a  liberal  diet. 

1.  Weight  and  strength  are  better  maintained. 

2.  Toxemia  is  less. 

3.  Distension  is  uncommon. 

4.  Convalescence  is  shorter. 

5.  Patients  suffer  less. 

E.  Medication.  Hexamethylenamiiie  (p.  289)  should  be  pre- 
scribed by  routine  as  a  urinary  antiseptic.     It  may,  rarely,  cause 


[83] 

hematuria  or  painful  micturition.  It  should  then  be  omitted  for  a 
few  days  and  resumed  in  smaller  dosage. 

Other  drugs  may  be  ordered  occasionally  for  special  symptoms 
as  required. 

Antipyretics  should  not  be  prescribed  to  reduce  fever,  but  they 
may  be  used  for  headache,  in  the  early  stages  of  typhoid.  Being 
depressants  they  are  dangerous  when  the  circulation  is  impaired. 

F.  Observation. 

I.  Examine  the  patient  once  or  more  daily  during  the  febrile 
stage.    Look  for: 

1.  Signs  of  circulatory  weakness. 

2.  Pulmonary  hypostasis. 

3.  Bed  sores. 

4.  Changes  in  the  condition  of  the  abdomen. 
{a)   Distension  of  abdomen. 

{b)    Spasm. 

{c)    Tenderness. 

id)   Distension  of  bladder  from  retention. 

II.     Keep  track  of: 
I.  Urinary  excretion. 
1.  Nourishment. 

3.  Account  for  changes  in  pulse  or  temperature.  They  may  be 
the  first  sign  of  hemorrhage  or  perforation. 

4.  Keep  sterile  salt-solution  ready  for  use  by  hypodermoclysis 
or  intravenously  in  case  of  need. 

III.  It  is  the  duty  of  the  physician  carefully  to  supervise  treat- 
ment during  the  period  when  hemorrhage  or  perforation  may  occur, 
and  he  himself  or  his  assistant  should  be  accessible  at  times  when 
emergencies  may  arise. 

G.  Nursing. 

The  nurse's  general  duties  are  to  do  her  utmost  to  spare  the 
patient  exertion,  discomfort  and  mental  unrest;  to  report  to  the 
physician  at  his  visit  all  changes  in  the  condition  of  the  patient; 
to  be  prepared  to  answer  questions  as  to  the  effect  of  treatment 
prescribed;  and  to  notify  the  physician  at  once  of  alarming  symp- 
toms or  signs  suggesting  severe  hemorrhage  or  perforation.  She 
should  know  the  possible  significance  of  sudden  changes  in  pulse- 


[85] 

rate  and  temperature  and  should  look  for  blood  in  every  fecal 
dejection.  To  prevent  accident  she  should,  as  far  as  possible, 
avoid  leaving  the  patient  alone  even  when  he  is  not  apparently 
delirious. 

The  following  complications  can  generally  be  prevented  by  an 
experienced  nurse :  — 

I.   Bedsores.  5.   Boils. 

1.   Corneal  ulceration.  6.   Cracked  lips. 

3.  Middle-ear  infection.  7.   Tender  toes. 

4.  Parotitis.  8.   Hypostatic  congestion. 

1 .  To  prevent  bed  sores :  — 

{a)   Keep  sheets  smooth,  clean  and  dry. 

{h)    After  soiling,  clean  the  skin  promptly,  dry  it,  rub  in  zinc 

oxide  ointment,  and  powder  with  starch. 
if)    Change  the  patient's  position  occasionally. 
{d)   Do  not  allow  prolonged  pressure  on  bony  prominences. 
{e)    If  a  red  spot  appears  where  there  has  been  pressure  keep 

pressure  off  that  part  by  rings  or  pads  and  paint  the 

spot  with  picric  acid,  i  per  cent. 

2.  To  prevent  corneal  ulceration  keep  cornea  clean  by  bathing 
the  eyes  every  four  hours  with  a  1  per  cent  watery  solution  of  boric 
acid. 

3-4.  Middle-ear  infection  or  parotitis  may  result  from  improper 
care  of  the  mouth.  The  mouth  should  be  cleaned  and  the  throat 
sprayed  every  four  hours  with  a  non-irritating  antiseptic.  Dobell's 
solution,  or  "  alkaline  antiseptic  "  will  serve,  diluted,  if  necessary, 
with  one  or  two  parts  of  water  to  avoid  irritation  of  the  mucous 
membranes.  Excessive  dryness  of  the  tongue  from  mouth  breath- 
ing can  be  prevented  by  the  use  of  vaseline. 

5.  Boils  in  crops  are  generally  due  to  the  use  of  dirty  sponges. 
If  a  boil  appears  care  must  be  taken  to  avoid  spreading  the  infec- 
tion. 

6.  Cracked  lips  can  be  prevented  by  the  use  of  cold  cream. 

7.  To  prevent  "  tender  toes  "  keep  weight  of  bed-clothing  off 
of  feet. 

8.  Hypostatic  congestion  of  the  bases  of  the  lungs  is  due  in 
part  to  protracted  lying  in  one  position.  It  can  be  combated,  if 
not  prevented,  by  rolling  the  patient  on  one  side  and  supporting 


[87] 

him  in  this  position  for  an  hour  or  more  by  means  of  a  pillow. 
The  patient  should  then  be  rolled  onto  the  other  side  for  another 
period  of  time,  and  these  manoeuvres  should  be  practiced  at  least 
once  daily. 

ROUTINE  ORDERS  TO  NURSE. 

I.   Enteric  precautions. 

1.   Dr.  Shattuck's  enteric  diet.     (Prof.  F.  C.  Shattuck.) 

3.  Baths  as  directed  every  four  hours,  p.r.n. 

4.  Suds  enema  every  other  day  or  p.r.n. 

5.  Spray  throat  and  wash  mouth  and  eyes  every  four  hours. 

6.  Hexamethylenamine,  5  grs.  (or  0.3  gm.)  t.i.d. 

7.  Record  temperature,  pulse  and  respiration  every  four  hours, 
the  daily  excretion  of  urine,  and  the  amount  of  food  and  water 
ingested. 

Specific  directions  for  diet  and  baths  should  be  given  with  due 
regard  for  the  circumstances  of  each  case.  Frequent  modifica- 
tion may  be  required. 

H.   Convalescence.    In  convalescence  free  evacuation  of  the 
bowels  is  important. 
Massage  may  hasten  return  of  strength. 

SYMPTOMATIC  TREATMENT  FOR  TYPHOID. 

Fever  and  Toxemia 

Hydrotherapy  generally  acts  well. 
Benefits  expected  from  it  are: 

1.  Fall  of  temperature  of  from  i  to  2  degrees. 

2.  Fall  in  rate  with  increase  of  force  and  volume  of  the  pulse. 

3.  Deeper  breathing  and  diminution  of  pulmonary  hypostasis. 

4.  Better  sleep. 

5.  Diminution  of  symptoms  of  toxemia. 

Rules  for  use  of  baths. 

I.   Baths  should  be  ordered  for  definite  indications  only. 
1.   For  children  and  for  thin  and  feeble  patients,  baths  should 
be  warmer  and  shorter  than  for  the  robust  adult. 

3.  The  physician  should  supervise  the  first  bath  and  prescribe 
subsequent  baths  with  regard  to  the  eflfect  of  the  first  one. 

4.  If  the  pulse  gets  weaker  the  bath  should  be  stopped. 


[89] 

5-  Much  cyanosis  or  shivering  after  the  bath  indicates  that.it 
was  too  cold,  or  too  long,  or  that  not  enough  friction  was  used. 

6.  Stimulants  are  seldom  required  before  or  after  a  bath  that 
is  suited  to  the  case  and  well  given. 

7.  Baths  must  be  modified  or  omitted  if  they  greatly  excite  the 
patient,  interfere  with  sleep,  or  cause  a  rise  of  temperature. 

Routine  bath  order.  For  temperature*  of  103.5°  rectal  give 
bath  every  four  hours  at  85°.  For  every  half  degree  of  tempera- 
ture above  103.5°  lower  temperature  of  bath-water  5°. 

Methods  of  bathing.  "  M.  G.  H.  Typhoid  Bath."  With 
rubber  sheet,  supported  at  edges  by  rolls  of  blanket  make  tub  in 
bed  of  patient.  Dash  water  over  him,  and  rub  vigorously  in  turn, 
with  the  hands,  the  chest,  limbs,  and  back,  but  not  the  abdomen. 
The  duration  of  the  bath  should  be  20  minutes  or  less  if  so  ordered. 

Sponge  baths  often  act  well  and  are  preferred  in  many  cases. 
A  mixture  of  equal  parts  of  alcohol  and  2  per  cent  boric  acid  solu- 
tion in  water  at  the  required  temperature  can  be  used  for  bathing. 

Circulatory  Disorders. 

Indications  for  stimulation  are  tachycardia  of  120  or  over,  or 
weakness,  inequality,  or  irregularity  of  the  pulse,  see  Circulatory 
Disorders  of  Fevers  and  Sepsis,  p.  3^. 

For  treatment  of  circulatory  disorders  see  same  section.  Symp- 
toms generally  develop  gradually  giving  time  to  prescribe.  Saline 
infusions  give  excellent  results  in  suitable  cases. 

Diarrhea. 

Severe  diarrheas  are  dangerous  and  must  be  checked. 

1.  Examine  stools  to  determine  if  they  contain  undigested 
food.  If  so,  omit  that  kind  of  food  or  reduce  the  amount.  Curds 
from  milk  may  be  found. 

2.  Treatment  as  for  simple  diarrhea,  p.  225. 

Constipation. 

Constipation  is   a  frequent  cause  of  fever  in  convalescence. 


*  Temperatures  in  typhoid  are  best  taken  by  rectum  because  these  are  more  reliable 
than  mouth  temperatures.  The  rectal  temperature  averages  about  i°  higher  than  the 
mouth  temperature. 


[91] 

Calomel  or  Fl.  Ex.  of  Cascara  Sagrada,  Castor-oil  or  "  Russian 
oil "  (p.  297)  may  be  given  at  this  stage.  Neglect  of  the  bowels  may 
result  in  fecal  impaction. 

Distension. 

I.   If  stools  show  curds  reduce  or  omit  milk. 

1.  Turpentine  stupes  *  may  give  rehef  and  can  be  used  p.r.n. 
3.  Rectal  tube  may  be  tried. 

Vomiting. 

Reduction  or  modification  of  diet  is  advisable  for  a  time  at  least. 
Swallowing  small  pieces  of  cracked  ice,  or  a  teaspoonful  of  shaved 
ice  with  brandy  may  relieve. 

Headache. 

If  not  relieved  by  an  ice-cap  placed  on  the  forehead,  phenacetin 
fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.),  with  caffeine  citrate  i  gr.  (or 
0.065  g^Oj  or  some  other  analgesic  may  be  prescribed. 

COMPLICATIONS  OF  TYPHOID. 

I.   HEMORRHAGE  FROM  THE  BOWEL. 

Signs.  First  sign  of  small  hemorrhage  is  blood  in  the  stool. 
First  sign  of  large  hemorrhage  may  be  a  rapid  fall  in  temperature 
and  a  rise  in  the  pulse  rate. 

Treatment,     i.   Omit  nourishment,  water,  and  baths. 

2.  Give  nothing  but  cracked  ice  by  mouth  for  24  hours. 

3.  Give  morphine  subcutaneously  —  repeat  dose  in  15  minutes 
or  half  an  hour  and  repeat  again  at  half-hour  intervals  until  the 
respiration  becomes  slower.  Do  not  let  the  respiration  fall  below 
10  per  minute.  When  it  has  reached  15  or  less  give  morphine  in 
small  dosage,  if  at  all,  lest  poisoning  result. 

The  object  of  using  morphine  is  to  stop  peristalsis  and  to  keep 
the  patient  quiet  until  the  hemorrhage  has  ceased. 

4.  If  the  patient  be  exsanguinated  raise  the  foot  of  the  bed  to 
prevent  death  from  syncope  but  do  not  stimulate  unless  there  is 
imminent  danger,  because  increase  of  blood-pressure  may  prolong 
the  hemorrhage. 

*  See  textbook  on  nursing. 


[93] 

The  best  circulatory  stimulants  for  this  condition  are  a  saline 
infusion  or  a  direct  transfusion  of  blood. 

5.  For  small  hemorrhages  narcotization  with  morphine  may 
not  be  required. 

6.  Patients  who  are  ven.^  weak  or  emaciated  should  be  fed  in 
spite  of  hemorrhage. 

n.   PERFORATION. 

Treatment.  Surgical.  Early  diagnosis  and  prompt  operation 
are  essential  to  success.  When  the  condition  of  the  abdomen  has 
been  watched  closely  before  the  appearance  of  the  symptoms  of 
perforation  the  diagnosis  will  be  easier.  Spontaneous  recover}-  is 
extremely  rare. 

RHEUMATIC  FEVER. 

Note. —  The  disease,  when  typical,  is  characterized  by  a  mi- 
gratory articular  and  peri-articular  inflammation  with  pyrexia 
and  leucocytosis.  When  untreated  the  inflammation  generally 
lasts  aboui-  six  weeks.  Relapses  are  common  and  endocarditis 
is  frequent.     Pericarditis  or  myocarditis  is  seen  occasionally. 

There  is  reason  to  believe  that  rhemnatic  fever  is  a  form  of 
infectious  arthritis.  Perhaps  most  of  the  cases  are  due  to  a  specific 
organism. 

PRTNCrPLES  OF  TREATMENT. 

1.  Rest  in  bed. 

2.  Relieve  pain. 

3.  Dilute  and  eliminate  toxins. 

4.  Prescribe  large  quantities  of  saHcylate  and  of  alkali. 

5.  Prevent  recurrence. 

6.  Watch  for  cardiac  complications. 

METHODS. 

I.  Relieve  pain  by  protecting  the  joints  with  cotton  and  band- 
ages or  by  splints.  For  psychic  effect  oil  of  gaultheria  may  be 
rubbed  on  the  skin  before  bandaging.  Fomentations  may  be 
useful  to  relieve  pain  and  a  hot  tub  bath  when  pain  and  fever  permit 
gives  much  relief.  If  the  pain  be  severe  and  not  controlled  by 
other  means  use  morphine  hypodermically  until  the  salicylate  has 
had  time  to  act. 


195J 

2.  Dilution  and  elimination  of  toxins  can  be  promoted  by  the 
free  administration  of  water.  Three  quarts  or  more  should  be 
ingested  in  twenty-four  hours  unless  the  heart  be  weak.  Cardiac 
complications  may  require  limitation  of  liquids. 

The  bowels  should  be  kept  clear.  Cathartics  may  be  pre- 
scribed as  needed. 

3.  Food  should  be  nutritious  and  as  abundant  as  can  be  digested 
because  wasting  is  often  rapid  and  anemia  may  develop. 

4.  Medication.  Sodium  salicylate  (p.  287)  or  some  other  saHcyl 
compound  should  be  prescribed  in  large  dosage.  The  quantity 
should  be  proportional  to  the  degree  of  pain  and  acuteness  of  the 
inflammation.  For  severe  cases  10  grs.  (or  0.65  gm.)  may  be 
ordered  every  hour  until  the  patient  is  relieved  or  toxic.  To 
avoid  irritation  of  the  stomach  every  dose  should  be  given  with  a 
full  glass  of  water.  Large  doses  of  sodium  bicarbonate  seem  to 
diminish  the  toxic  effects  of  salicylates.  Twenty  grains  or  more 
of  soda  may  be  ordered  with  every  dose  of  salicylate.  Enough  soda 
should  be  taken  to  render  the  urine  alkaline. 

Sahcin  is  a  good  substitute  for  sodium  salicylate  and  seems  to 
cause  less  gastric  disturbance.  Aspirin,  or  oil  of  gaultheria,  may 
be  tried. 

When  symptoms  have  been  relieved  the  dose  of  the  drug  can 
be  reduced.  It  should  be  continued  for  a  month  or  more  after 
the  patient  is  apparently  well. 

When  salicylates  act  well,  in  from  twenty-four  to  forty-eight 
hours,  a  fall  of  temperature  occurs,  and  with  it  there  comes  diminu- 
tion of  joint  swelling  and  marked  relief  from  pain. 

The  common  symptoms  of  salicylate  poisoning  are  nausea  or 
vomiting,  tinnitus,  headache  and  occasionally  erythema  or  deli- 
rium. When  these  occur  the  drug  must  be  omitted  until  they 
subside.  It  may  then  be  resumed  in  smaller  dosage  or  in  different 
form. 

5.  Recurrence  of  arthritis  is  common  early  or  late. 

Early  recurrence  can  generally  be  avoided  by  keeping  the 
patient  in  bed  for  a  week  after  the  inflammation  has  entirely 
subsided  and  by  continuing  the  use  of  sodium  salicylate,  30  to 
40  grs.  (or  2  to  3  gm.)  daily,  for  one  month  or  more  after  con- 
valescence.    Exercise  should  be  resumed  gradually. 


[97 

Late  recurrence  and  future  cardiac  disease  can  often  be  pre- 
vented by  eliminating  all  foci  of  suppuration.  Inflammation  of 
the  tonsils  or  genital  tract,  sinus  infection  and  pyorrhea  alveolaris 
should  be  looked  for.  Tonsillectomy  may  reveal  deep  suppuration 
not  demonstrable  externally.  Tonsillectomy  *  should  be  insisted 
on  if  the  tonsils  are  a  likely  source  for  future  infection.  Pyorrhea 
can  be  benefited  by  rubbing  the  gums  daily  with  a  i%  solution 
of  potassium  permanganate  and  by  rinsing  or  sponging  the  mouth 
frequently  with  hydrogen  peroxide. 

6.  Cardiac  complications  may  be  latent  or  severe.  Circulatory 
weakness  may  require  limitation  of  liquids. 

The  patient  should  remain  flat  in  bed  for  weeks  or  months  after 
the  disappearance  of  all  signs  of  active  cardiac  infection,  and  should 
avoid  exertion  of  all  kinds  for  several  months  thereafter  to  give  the 
heart  ample  time  to  hypertrophy  or  to  adjust  itself  to  the  changes. 

There  is  reason  to  believe  that  salicylates  taken  in  large  quantity 
tend  to  ward  oflF  endocarditis. 

For  further  information  on  endocarditis,  see  Chapter  I,  page  27. 

*  Dangerous  while  the  tonsils  are  acutely  inflamed. 


99 


CHAPTER  IV. 

ACUTE  INFECTIONS  MOST  COMMON  IN 
CHILDHOOD. 

By  Edwin  H.  Place,  M.D. 

SCARLET  FEVER. 
I.   MANNER  OF  SPREAD. 

A.  Exit  of  virus  —  chiefly  from  throat  and  nose  or  infected 
ear,  and  from  other  lesions  of  mucous  membrane  or  skin,  such  as 
impetigo,  boils,  sinuses,  etc.  Probably  no  escape  of  virus  from 
sound  mucous  membrane,  nor  in  urine  or  feces.  None  in  desqua- 
mating skin. 

B.  Viability  of  virus  —  apparently  may  survive  many  days 
and  possibly  weeks  or  months.  Under  ordinary  conditions  of 
light  and  air,  probably  dies  in  a  few  days,  and  in  sunlight  in  a  few 
hours. 

C.  Manner  of  transfer  —  chiefly  by  direct  contact;  also  by 
indirect  contact  and  droplets.  Milk,  the  only  known  food  to 
spread  contagion  —  no  gross  changes  in  infected  milk. 

T>.  Point  of  entry  —  almost  certainly  the  throat  and  possibly 
nose;  possibly  wounds,  and  gastro-intestinal  system. 

E.  Persistence  of  virus  —  persists  for  some  time,  (weeks  or 
months)  in  lesions  of  skin  or  mucous  membrane  where  there  is  any 
loss  of  continuity  of  epithelial  lining.  The  more  active  the  in- 
flammation of  these  lesions  and  the  greater  the  discharge,  the  more 
probable  is  contagiousness.  Most  contagious  period  is  usually 
early  during  the  stage  of  acute  throat  and  nose  inflammation  but 
varies  directly  with  the  amount  of  mucous  membrane  inflammation 
so  that,  in  some  cases,  the  highest  contagiousness  is  in  late  con- 
valescence. I  have  never  found  a  longer  contagious  period  than 
5  months. 

II.   PROPHYLAXIS. 

One  attack  usually  gives  immunity  for  life  but  there  are 
marked  exceptions. 


[lOl] 

A.  Immunity. 

1.  Natural.  Increases  much  after  8  years  of  age  and  marked 
after  21  years,  considerable  during  ist  year  and  lowest  from  2  to 
6  years  of  age, 

2.  Active.  Claimed  by  Gabritschusky  by  means  of  vaccines 
of  streptococci  obtained  from  scarlet  fever  cases.  Three  injections 
at  intervals  of  4  days,  of  doses  of  from  one  to  ten  millions  may  be 
used.    Value  very  doubtful. 

B.  Asepsis.     See  under  diphtheria  (p.  131). 

C.  Isolation  —  of  great  value  and  should  be  as  early  as  possible. 
Finding  of  missed  cases  in  family  or  neighborhood  or  school  often 
possible  by  investigation  at  the  time  of  the  first  recognized  case. 
These  should  be  searched  for  in  each  recognized  case  by  examination 
of  contacts  for  evidence  of  sore  throat,  sore  nose,  discharging  ears, 
glands,  nephritis,  arthritis,  endocarditis,  desquamation  or  any  sore 
or  discharging  lesion.  The  finding  of  these  signs  does  not  neces- 
sarily show  that  patient  has  had  scarlet  fever,  but  they  should  be 
accepted  at  least  as  grounds  for  suspicion  and  therefore  isolation. 
Isolation  should  be  carried  on  for  four  weeks  and  until  there  are 
no  abnormal  discharges  or  open  sores. 

I.  Technic.  Technique  of  isolation  is  that  of  surgical  asepsis 
reversed,  /.  f .,  to  keep  infection  in  a  small  zone  instead  of  a  small 
area  free  from  infection.  Air  currents  play  no  practical  part  in 
spreading  the  disease. 

{a)   Avoid  infecting  clothing  of  attendants  or  utensils  from 
careless  touching  of  patients  or  putting  infected  hand 
or  things  into  pockets,  etc.    Wear  gowns. 
{b)   Wash  hands  thoroughly  on  leaving  zone  of  infection.  Do 
not  handle  face  or  uninfected  objects  until  hands  are 
thoroughly  cleansed.     Be  careful  of  door  knobs. 
(c)    Boil  dishes,  utensils,  etc.,  as  they  leave  patient.     Do  not 
put  down  infected  dishes,  etc.,  in  an  uninfected  zone. 
{d)   Boil  clothes  or  soak  them  in  5  per  cent  phenol  solution  or 
similar  germicidal  solution.     Be  careful  not  to  infect 
surroundings  in  removing  these  objects  from  the  in- 
fected zone. 
((?)    Use  care  to  prevent  discharges  from  nose,  throat,  ear, 
etc.,  from  being  spread  about  sick  room     Use  soft  piece 


of  paper,  towel  or  cloth  and  deposit  at  once  in  paper 
bags  or  burn. 

(/)  Do  not  allow  infected  objects  as  thermometer,  pencils, 
stethoscope,  books,  money,  etc.,  to  be  taken  from 
infected  zone  without  proper  disinfection. 

(g)  Thorough  cleansing  of  patient  when  released  from  in- 
fected zone,—  while  of  questionable  importance, —  still 
must  be  done.  The  mouth  should  be  thoroughly 
cleansed  and  antiseptic  sprays  may  be  used  in  the  nose, 
although  value  is  uncertain.  Patients  should  not  be 
released  until  all  signs  of  inflammation  of  mucous  mem- 
branes have  entirely  subsided. 

D.  Quarantine-  Exposed  persons  should  not  be  allowed  to 
go  to  new  places  or  come  in  contact  with  others  as  in  school 
or  social  assembly,  etc.,  until  2  weeks  after  the  last  exposure. 
Care  should  be  taken  to  see  that  they  have  not  a  mild  and  over- 
looked infection.  Closing  of  school  is  unnecessary  provided  care- 
ful study  of  the  pupils  is  made  to  eliminate  those  who  are  ill  or 
who  are  carriers.  Adults  unless  dealing  in  raw  foods,  especially 
milk,  cream  and  ice  cream  need  not  be  quarantined  as  a  rule. 

E.  Disinfection.  —  of  doubtful  value  as  a  general  measure  of 
control.  Proper  cleanliness  and  asepsis  about  patient  obviates 
this  necessity.  In  well-lighted  and  aired  rooms,  objects  that 
might  have  been  infected  have  usually  ceased  to  be  a  source  of 
danger  by  the  time  the  patient  has  ceased  to  harbor  the  organisms 
and  can  be  released.  Disinfection  can  be  done  by  exposure  to 
sun,  by  thorough  cleansing  and  washing  with  soap  and  water  and 
germicidal  solutions  such  as  phenol  or  corrosive  sublimate  or  by 
thorough  and  prolonged  exposure  to  formaldehyde  gas.  All 
things  that  can  be  boiled,  as  linen,  etc.,  should  be  so  treated. 

III.   TREATMENT. 

The  great  dangers  of  scarlet  fever  are  sepsis,  cardiac  involve- 
ment, nephritis  and  toxemia.  Of  these  sepsis  is  by  far  the  greatest 
factor  in  mortality. 

yf .    Toxemia,  treatment  of :  — 

I.  Serum  treatment.  Convalescent  patient's  blood  serum  50 
to  100  cc.  should  be  used  intravenously  preferably.     The  con  vales- 


LI05J 

cent's  blood  may  be  obtained  1-3  weeks  after  temperature  becomes 
normal.  Testing  for  syphilis  and  bacterial  contamination  should 
be  done  before  using  senjm;  this  treatment  is  of  limited  applica- 
tion but  has  some  value.  The  whole  blood  of  convalescent 
either  citrated  or  injected  as  soon  as  drawn  may  be  used  for  intra- 
muscular injections. 

Antistreptococcus  serum  obtained  from  horses.  Moser's  serum, 
obtained  by  injecting  horses  with  many  strains  of  streptococci 
cultivated  from  scarlet  fever  patients,  may  be  used  in  doses  of  at 
least  200  cc.  It  is  of  little  value  in  some  cases  and  often  disap- 
pointing. 

2.  Free  fluid  intake.  i|  litres  daily  according  to  age.  If 
patients  do  not  take  fluid  freely  it  may  be  given  by  rectum  or  sub- 
cutaneously  or  in  very  toxic  cases  intravenously  as  salt  solution. 

3.  Eliminative  treatment.  Mild  catharsis.  Daily  warm  bath, 
etc. 

4.  Rest  in  bed. 

B.    General  Sepsis,  treatment  of :  — 
I .    Prevention. 

{a)   Guarding  portals  of  entry. 

(i)  Local  cleansing  of  mouth,  gums,  teeth,  etc.,  with 
cotton  swab  applicator  2  or  3  times  daily.  Saline 
solution,  soda  bicarb,  solution,  borax  solution  or  a  com- 
bination of  these  with  10  or  20  per  cent  glycerine  or  other 
mild  cleansing  solution  may  be  used  such  as  Dobell's. 

(2)  Protection  of  mucous  membranes  from  trauma,  etc. 
Albolene  and  similar  petroleum  oils  are  of  value  following 
cleansing  of  mouth,  especially  in  mouth  breathers,  and 
where  there  is  mucous  membrane  infection.  Carious 
teeth,  old  roots,  tartar  deposits,  etc.,  should  be  seen  to. 

(3)  Antiseptics.  Phenol,  eucalyptus,  argyrol,  silver  ni- 
trate, iodine,  etc.,  are  of  doubtful  value.  Their  use  may 
cause  chemical  injuries  to  mucous  membrane.  If  used, 
careful  consideration  should  be  given  to  the  amount  of 
harm  they  do  to  tissue  as  well  as  to  bacteria.  The  least 
injurious  to  tissue  are  usually  best. 

(4)  Nasal  infection.  Nasal  infection  and  nasal  vault 
infection  as  well  as  accessory  sinus  disease  may  be  sources 


[  I07  J 

of  danger  but  are  difficult  to  treat  effectually.  Mechani- 
cal cleansing  by  swabs  is  allowable.  Syringing  is  liable 
to  cause  injury,  or  spread  infection.  Patient  may  clear 
the  nose  by  blowing,  if  old  enough;  application  of  oint- 
ment and  medicated  oils  for  protection  and  mild  anti- 
septic action  is  of  value. 

(5)  Tonsillectomy.  Removal  of  tonsils  and  adenoids  as 
early  as  possible  in  the  acute  stage  of  infection  has  been 
suggested  and,  in  practice,  seems  to  be  beneficial.  In  a 
limited  number  of  cases  in  which  tonsillectomy  has  been 
done  in  early  stage  of  scarlet  fever  a  very  favorable 
course  has  followed. 

{b)    General  Hygiene. 

1.  .Treatment.  Same  as  prevention.  Rest  in  bed,  free  fluids, 
baths  and  alcohol  rubs,  cocoa  butter  rubs,  ice  cap  or  ice  collar, 
sunshine,  fresh  air,  outdoor  treatment.  Secure  sleep  and  comfort 
by  alleviating  cause  of  discomfort  by  any  means  available.  Sleep 
and  rest  should  not  be  sacrificed  to  the  use  of  antiseptics,  etc. 
Supply  energy  by  easily  assimilated  foods.  Sugar  is  of  great 
value. 

C    Local  Sepsis,  treatment  of :  — 

1.  Throat.  Antiseptics  of  questionable  value.  Cleanliness 
and  soothing  treatment  is  principle.  Swabbing  local  lesions  care- 
fully with  one-half  strength  hydrogen  peroxide,  20  per  cdnt 
argyrol,  iodine  preparation,  5  to  50  per  cent  silver  nitrate,  or  2  to  4 
per  cent  chromic  acid  solutions  selectively  used  may  be  of  benefit. 
Hot  irrigations  often  help.  Coughing  and  struggling  when  irriga- 
tions are  given  contraindicate  their  use. 

2.  Nose.  Cleansing  of  nose  by  the  patient  blowing  is  better 
and  safer  than  irrigations.  Sprays  are  of  little  value  but  may  be 
used. 

Instillations  of  15  per  cent  argyrol,  or  camphor,  gr.  ii,  menthol, 
gr.  ii,  and  iodine,  gr.  i,  in  albolene,  i  oz.  may  be  tried.  Plain 
albolene  instillation  often  of  value. 

Insufflations  of  calomel  powder  twice  daily  are  often  of  value. 

3.  Otitis  Media. 
{a)   Prevention. 

(i)  Avoid  nasal  irrigation,  palpation  of  nasal  vault  for  ad- 


[109] 

enoids,  coughing,  forcible  washing  of  throat,  Trendelen- 
berg's  position,  etc. 

(2)  Prevent  obstruction  of  nose  from  acute  swelhng — 
by  oily  instillations  or  sprays  as  above.     Adrenalin  i  to 
8000  in  oily  preparations  (adrenalin  inhalant)  may  some- 
times help.    Ten  drops  of  15  per  cent  argyrol  may  be 
instilled  into  the  nostril  and  allowed  to  run  down  into  the 
fossa  of  Rosenmtiller  by  holding  head  to  that  side  while 
in  the  supine  position  for  20  minutes. 
Note. —  Previous  abnormalities  of  nasal  vault,  such  as  adenoids, 
large  turbinates,  etc.,  as  well  as  attempts  at  local  asepsis  are  im- 
portant factors  in  causing  otitis. 

{F)    Treatment. 

(i)  Treatment  of  nose  and  nasal  pharynx  as  above. 

(2)  Free  drainage  by  cutting  drum  if  bulging.  Repeat  it 
as  often  as  necessary. 

(3)  Irrigations  ev.  2  to  4  hours  with  boric  acid  or  saline 
solution  at  100  to  no  degrees  Fahrenheit. 

(4)  The  dry  treatment  may  be  used  instead  of  irrigations 
especially  when  discharge  is  thin.  It  consists  of  frequent 
sponging  out  with  sterile  cotton  and  keeping  in  a  narrow 
wick  to  the  drum  but  not  closely  filling  the  canal.  Wick 
must  be  changed  as  soon  as  saturated.  To  this  may  be 
added  later  boric  powder  insufflations  or  instillations  of  5 
per  cent  boric  acid  in  15  per  cent  alcohol  solution.  Silver 
salts  and  other  antiseptics  are  of  questionable  value. 

(5)  Watch  for  symptoms  of  mastoiditis. 

4.    Mastoiditis. 

{a)   Prevention.    Watch  and  promptly  treat  otitis  media. 

{]))    Treatment. 

(i)  Prompt  drainage  of  middle  ear  by  paracentesis.  Re- 
peat as  often  as  necessary.  Copious  irrigations  every 
2  hours — hot.  Applications  of  ice  to  the  mastoid  process. 
(2)  Operation  is  indicated  if  tenderness  persists,  if 
edema  increases  or  if  temperature  remains  up  for  more 
than  3  days.  Operation  may  be  desirable  even  in  the 
absence  of  these  signs.  Continued  discharge  alone  may 
be  an  indication. 


[Ill] 

5.  Cervical  Adenitis. 
{a)    Prevention. 

(i)  Throat  and  mouth  cleanhness,  attention  to  teeth, 
gums,  etc. 

(2)  Removal  of  tonsils  and  adenoids.  Even  in  an  acute 
stage  of  the  disease  removal  of  the  tonsils  has  given  highly 
favorable  results,  but  further  experience  is  desirable. 

(3)  Treatment  of  diseases  of  the  nose  and  accessory- 
sinuses. 

{b)    Treatment. 

(i)  Ice  applications  the  first  few  days;  poultices  after- 
ward. Resolution  without  pus  often  occurs  with  poul- 
tices. 

(2)  Treat  throat,  mouth  and  nose  as  needed. 

(3)  Chemical  applications  as  methyl  salicylate,  iodine 
petrogen,  ointment  of  colloidal  silver  (Crede)  are  of  very 
doubtful  value  but  may  be  used. 

(4)  Incision  if  suppuration  occurs.  Best  results  obtained 
by  not  incising  too  early,  allowing  pus  to  become  localized 
and  the  induration  to  subside.  Burrowing  of  pus  is  rare. 
If  it  occurs  incise  very  promptly.  Incision  should  be  as 
short  as  possible  and  in  lines  of  cleavage  of  the  skin  to 
avoid  scar. 

6.  Pyemia. 

Incisions  and  drainage  as  lesions  develop. 

7.  Arthritis. 

•  {a)  Simple.  (Scarlatinal  arthritis  and  periarthritis.)  Self- 
limited  to  a  few  days.  Rest.  Immobilization  by 
cotton  batting  bandages  or  splints.  Applications  of 
methyl  salicylate  dressings,  etc. 
{b)  Septic.  Incision  as  early  as  diagnosis  has  been  made. 
Thorough  and  prolonged  washing  out  of  cavity  and 
sewing  tip  tight  has  given  the  best  result.  Incision 
followed  by  rubber  dam  drains  has  not  been  so  favor- 
able.    Immobilization. 

8.  Phlebitis    (rare).     Elevation    for   circulation.     Local   heat 
such  as  poultices.     Citric  acid  internally  may  be  used. 


[113] 

9-   Arterial  Thrombosis  (rare).     Elevation,  local  heat,  amputa- 
tion only  after  line  of  demarkation  has  formed. 

10.  Empyema.     Drainage  by  operation. 

11.  Peritonitis  (rare).     Operation  required. 

12.  Local  infections  may  be  benefited  by  autogenous  vaccines. 

D.  Nephritis. 
I.   Prevention. 

{a)   Attempt  to  reduce  toxemia  of  acute  stage.     See  under 

toxemia. 
{b)    Kidney  rest. 

(i)  Rest  in  bed  for  at  least  three  weeks  in  all  cases. 

(a)  Avoid  excessive  loss  of  heat  and  continued  chilling 

of  skin. 

(3)  Free  fluid  intake  in  the  absence  of  edema  probably 
benefits  the  kidney. 

(4)  Diet.  Low  protein,  chiefly  carbohydrate  and  fat. 
Avoid  extractives,  nucleo-proteids  and  foods  rich  in  purin. 
Cream  and  milk,  one  to  two  pints,  cereals,  especially 
wheat,  rice,  baked  potatoes,  tapioca,  sugar,  sweet  fruits, 
bread,  green  vegetables,  except  asparagus.  In  the  acute 
stage  patient  may  refuse  everything  but  fluids.  Sugar 
may  be  used  at  this  time  freely. 

(5)  Daily  hot  bath. 

(6)  Salt  intake  may  be  reduced  but  value  is  uncertain. 
Alkalis  may  be  given. 

I.   Treatment.    See  Nephritis,  page  61. 
1.   Uremia.     See  page  71. 

E.  Cardiac  complications. 
I.   Endocarditis. 

{a)    Prevention. 

(i)  Avoid  and  promptly  treat  local  infection  as  alveolar 
abscess,  otitis  media,  septic  joints,  diseased  tonsils, 
accessory  sinus  disease  and  other  focal  infections,  which 
may  be  responsible  for  infection. 

(2)  Prevent  exertion  during  the  period  likely  to  be  at- 
tended by  cardiac  complications. 

(3)  Reduce  Toxemia. 


[115] 

{b)    Treatment. 

(i)  Rest  to  be  as  complete  as  possible,  prolonged  until 
lesion  has  entirely  healed  —  2  to  6  mos.  Cardiac  stimu- 
lants are  contraindicated  because  cardiac  insufficiency 
does  not  develop  early.  An  ice-bag,  aconite,  or  br>"onia 
may  perhaps  give  the  heart  relative  rest  by  quieting  its 
action. 

(2)  Salicylates.     Danger  of  kidney  injury  must  be  kept 
in  mind. 
2.   Pericarditis.    The  same  as  endocarditis. 
Morphine  may  be  necessary  because  of  pain.     Posture  may 
need  to  be  upright  also  for  this  reason.     Fluid  may  require  as- 
piration.    Pus  will  require  operation  and  drainage. 

F.  Fever.  Usually  self-limited,  not  prolonged.  Alcohol  rubs, 
cold  sponges,  cold  baths,  may  be  used  for  a  stimulant  effect. 
Friction  of  the  skin  is  usually  advisable  while  using  cold  treat- 
ment. Friction  alone  using  cocoa  butter  may  also  reduce  temper- 
ature, stimulate  vaso-motors  and  add  to  comfort, 

MEASLES. 

I.   MANNER  OF  SPREAD.  ' 

A.  Exit  of  virus  —  from  nose  and  throat  and  possibly  from 
conjunctiva;  none  by  desquamation. 

B.  Viability  of  virus — slight;  apparently  does  not  survive 
under  any  known  natural  condition  more  than  one  or  two  days. 
Usually  dies  in  a  few  hours  especially  in  light  or  sunny  conditions. 

C.  Manner  of  transfer  —  by  droplets  and  direct  contact;  at 
times  by  indirect  contact;   none  by  food. 

D.  Point  of  entry  —  probably  respiratory  tract,  especially 
nose  and  throat. 

E.  Persistence  of  virus  —  dies  with  the  establishment  of  con- 
valescence or  earlier;  does  not  persist  after  subsidence  of  measles 
rash  without  regard  to  secondary  infections  such  as  otitis  media. 
Most  contagious  period  —  catarrhal  stage. 

n.   PROPHYLAXIS. 

A.  Immunity.  Practically  none  naturally  except  during  first 
year  of  life  especially  first  6  mos.  Immunity  after  one  attack 
very  great  and  almost  always  complete. 


[117] 

B.  Asepsis.  Particularly  difficult  in  general  life  because  of 
droplet  infection.  The  most  casual  contact  will  allow  the  disease 
to  be  contracted.  Avoid  the  region  of  persons  who  sneeze.  Keep 
hands  clean  and  avoid  touching  mouth  or  nose  with  infected  hands 
or  infected  objects. 

C.  Isolation  —  of  little  general  value  because  of  the  contagious- 
ness of  the  disease,  and  the  appearance  of  contagiousness  usually 
several  days  before  the  disease  is  recognized.  Isolation  to  be  of 
any  value  should  be  secured  early  in  the  catarrhal  stage,  and  con- 
tinued until  the  acute  catarrhal  stage  has  subsided,  that  is,  from 
seven  to  fifteen  days.    There  are  no  carriers. 

Technic.  Patient  must  be  isolated  so  that  droplet  infection 
may  not  be  carried  to  others,  otherwise  technic  same  as  for 
scarlet  fever  except  of  much  less  importance. 

D.  Quarantine.  The  one  effective  means  of  control.  Sus- 
ceptible exposed  persons  should  be  kept  from  contact  with  non- 
immunes until  three  weeks  from  the  last  exposure.  The  disease 
cannot  be  stopped  in  schools  by  inspection  and  requires  closing  of 
the  schools  if  it  is  desired  to  check  the  epidemic.  Closing  of  the 
schools  to  be  of  value  requires  prevention  of  continued  contact 
of  the  families  of  a  community. 

E.  Disinfection  —  of  practically  no  general  value.  Measles 
contagion  dies  with  extreme  rapidity  and  probably  invariably 
within  24  hours  after  leaving  body  under  ordinary  conditions. 
Surroundings  of  patients  who  have  recovered  have  ceased  to  be 
infectious. 

m.   TREATMENT. 

The  chief  cause  of  death  is  secondary  infection  of  mucous 
membranes  of  which  pneumonia  is  of  greatest  importance.  Treat- 
ment, therefore,  should  be  directed  against  mucous  membrane 
infection,  especially  of  the  lungs. 

A.  Acute  toxemia. 

I.    Free  fluid  intake. 

1.  Cathartics  must  be  used  carefully  to  avoid  causing  diar- 
rhea. 

3.    Stimulation. 

{a)   Tepid  baths  or  cool  sponging. 

{b)    Friction  to  skin,  as  cocoa  butter  rubs,  etc. 


[119] 

B.  Mucous  membrane  infections. 
I .    Bronchopneumonia. 

{a)   Prevention. 

(i)  General  resistance.  Fresh  air,  sunshine,  rest  in  bed, 
and  food  easy  to  digest  and  to  absorb  help  to  maintain 
resistance. 

(2)  Local  resistance.  Mouth  cleanliness,  prevention  of 
nasal  and  laryngeal  obstruction,  soothing  oily  sprays 
may  do  good. 

(3)  Avoidance  of  contact  with  other  infections  as  colds, 
diphtheria,  etc. 

{b)   Treatment.     See  pneumonia,  page  153. 
1.    Acute  laryngitis. 

{a)   Expectorants  of  which  water  is  the  most  essential,  syrup 

ipecac,  syrup  hydriodic  acid,  etc. 
{b)    Steam  inhalations  with  compound  tincture  of  benzoin 

and  menthol,  followed  by  oily  sprays. 
{c)    Intubation  if  obstruction  occurs  and  requires  it. 
{d)   Antitoxin  in  all  cases  unless  diphtheria  has  been  excluded 

by  examination  of  the  larynx  and  taking  cultures  from 

the  larynx. 
(e)    Cold  applications  or  ice  collar  to  neck. 

3.  Tracheitis.     Same  as  laryngitis. 

4.  Otitis  Media.     See  scarlet  fever,  page  107. 

5.  Rhinitis. 

{a)   Soothing  applications,  oily  sprays. 

{b)    Atropine,  camphor,  etc.,  as  in  rhinitis  tablets. 

{c)    Argyrol  sol  io'/.-i5%  instillations  or  spray. 

6.  Stomatitis. 

{a)   Mouth  cleanliness. 

{b)  Hydrogen  peroxide  if  teeth  and  gums  are  foul  —  use 
once  or  twice  daily. 

{c)  Chromic  acid  solution,  2  to  4  per  cent:  apply  with  swab 
once  daily. 

id)   Removal  of  carious  roots,  bad  teeth,  etc. 

{e)  Careful  avoidance  of  trauma  of  any  kind.  Mouth  clean- 
liness, mild  antiseptic  solution  with  cotton  swab  appli- 
cators. 


[121] 

Iodine  preparations  and  silver  nitrate  may  have  value  in  certain 
selected  conditions. 

7.  Noma. 

{a)  Prevention.  Careful  attention  to  mucous  membranes 
of  the  mouth  prevents  stomatitis.  Avoid  trauma 
from  teeth  or  manipulations.  Treat  all  ulcers  promptly 
with  peroxide  and  apply  chromic  acid  solution. 
Watch  for  ulceration  at  edges  of  gums  especially  and 
treat  with  chromic  acid  solution  or  iodine. 

{b)  Treatment.  Escharotic  to  destroy  completely  the  in- 
fected area;  the  actual  cautery  is  the  best,  with 
chloroform  anesthesia. 

8.  Conjunctivitis. 

{a)   Boric  acid  solution  wash  three  times  daily. 
{b)   White  vaseline  for  lids. 
{c)    Avoid  injuring  cornea. 

9.  Entero-colitis. 

{a)  Prevention.  Avoid  overfeeding;  be  sure  that  milk  and 
other  food  is  free  from  contamination  or  is  pasteurized 
or  sterilized.  Avoid  unwise  catharsis.  Avoid  star- 
vation. 

{b)  Treatment.  Force  fluid,  cereal  diet,  bismuth  in  drachm 
doses  every  four  hours.     Beta-naphthol  may  be  tried. 


PERTUSSIS. 

I.   MANNER  OF  SPREAD. 

A.  Point  of  exit  —  from  nose  and  throat. 

B.  Viability  of  virus  —  apparently  dies  rapidly  outside  body. 
May  survive  1-2  days. 

C.  Manner  of  transfer  —  chiefly  by  droplets  also  by  direct 
contact;  rarely  by  indirect  contact. 

D.  Point  of  entry  —  Nose  or  throat. 

E.  Persistence  of  virus  —  persists  few  weeks  and  possibly  as 
long  as  characteristic  cough.  Most  contagious  period  —  early 
catarrhal  stage. 


fi23] 

n.  PROPHYLAXIS. 

A.  Immunity. 

1 .  Natural.     Extremely  low  in  early  life,  become  greater  after 
five  years  and  considerable  in  adult  life. 

2.  Active  immunity  is  claimed  by  means  of  vaccine.     Value  is 
uncertain.     One  attack  usually  gives  immunity. 

B.  Asepsis.     Similar  to  that  of  measles,  p.  1 17. 

C.  Isolation.     Similar  to  that  of  measles,  p.  117. 

D.  Quarantine.     Similar  to  that  of  measles,  p.  117. 

E.  Disinfection.     Similar  to  that  of  measles,  p.  117. 


ra.  TREATMENT. 

A.  Vaccines  still  remain  of  doubtful  value,  but  are  worthy  of 
trial.  Vaccines  containing  many  strains  of  the  Bordet-Gengou 
bacillus  should  be  used  —  dosage  of  from  100  million  to  a  1000 
million  may  be  used  at  intervals  of  from  two  to  five  days.  Mixed 
vaccines  con  taming  also  many  of  the  bacteria  commonly  infecting 
mucous  membranes  are  used. 

B.  Hygienic. 

1.  Building  up  general  resistance.  Fresh  air  and  sunshine. 
Rest,  varying  with  the  amount  of  prostration  or  fever. 

2.  Diet.  Easily  digested  foods  such  as  cereals,  milk,  bread 
and  butter,  rice,  simple  puddings,  chicken,  scraped  beef,  zwiebach, 
etc.  If  vomiting  occurs,  meals  should  be  frequent  and  small  in 
amount  and  given  if  possible  after  the  paroxysm.  If  a  meal  is 
vomited,  it  should  at  once  be  repeated.  High  protein  foods  are 
inadvisable  because  of  the  longer  stay  in  the  stomach  and  the 
danger  of  loss  from  vomiting. 

3.  Bitter  tonics,  iron,  etc.,  may  be  given.  Avoid  medicines 
which  might  upset  digestion. 

C.  Local  resistance.  Avoid  dust,  irritant  gases,  etc.  Oily 
sprays  as  albolene  or  albolene  with  other  sedatives  or  antiseptics 
to  nose,  throat  and  larynx  may  be  used.  Free  water  intake  is 
essential.  Inhalations  of  steam  with  menthol  and  creosote  are 
sometimes  useful  to  stop  the  paroxysm,  but  must  not  be  used  at 
the  expense  of  general  hygienic  treatment. 


[125] 

D.  Sedatives  should  be  used  only  when  demanded  for  severe 
cough  vv'hich  exhausts  the  patient  or  interferes  with  sleep  and 
nourishment.  Antipyrin  i  to  4  grs.  three  times  a  day,  or  Quinine 
Sulph.  2  to  5  gxs.  may  be  tried,  or  Tincture  of  Belladonna,  begin- 
ning with  I  to  3  min.  ev.  4  hours  and  increasing  until  the  physiologi- 
cal effect  appears  and  then  continuing  in  slightly  smaller  doses. 
Chloral  may  be  used  in  the  dose  of  2  to  5  grs.  once  or  twice  a  day. 
Benzyl  benzoate  in  doses  of  gr.  ii  to  gr.  xx  ev.  four  hours  may 
be  used. 

E.  Paroxysms  of  cough. 

I.  Fresh  air  day  and  night  is,  probably,  the  most  efficient 
means  of  diminishing  cough. 

1.  Psychic  treatment  —  calm  the  fear  of  patient  by  psychic 
suggestion  and  avoid  psychic  upsets  and  loud  noises. 

3.  Avoid  all  irritants. 

4.  Pressure  on  the  epigastrium  or  the  use  of  tight  bands  around 
the  abdomen. 

5.  Spraying  the  larynx,  with  sedative  solution  such  as  menthol 
or  by  inhalations  of  steam  with  benzoin  followed  by  menthol,  etc., 
are  of  limited  value. 

6.  Sedative  drugs:  see  above. 

F.  Complications. 

1 .  Bronchopneumonia. 
A.  Prevention. 

(i)  Fresh  air  and  sunshine  throughout  the  disease. 

(2)  Rest. 

(3)  Keep  up  nutrition  by  wise  feeding. 

(4)  Avoid  fatigue  from  paroxysms. 

(5)  Avoid  other  infections,  such  as  acute  colds,  irritants, 
such  as  dust,  etc. 

2.  Stomatitis.     See  Measles,  page  119. 

3.  Otitis  Media.     See  Scarlet  Fever,  page  107. 

4.  Cerebral  hemorrhages  may  be  guarded  against  by  attempt- 
ing to  control  severe  paroxysms  of  cough. 

5.  Vomiting.  Prevention  depends  on  control  of  cough.  The 
danger  is  malnutrition.  The  effects  can  be  minimized  by  fre- 
quent small  meals,  and  by  taking  food  promptly  after  vomiting. 


[127 


VARICELLA. 

I.   MANNER  OF  SPREAD. 

A.  Exit  of  virus  —  probably  only  through  the  varicella  lesions 
of  skin  and  mucous  membrane. 

B.  Viability  of  virus  —  apparently  survives  some  hours, 
days,  or  weeks. 

C.  Manner  of  transfer  —  direct  and  indirect  contact. 

D.  Point  of  entry  —  probably  mucous  membrane  of  throat  or 
nose;  possibly  gastro-intestinal  tract,  or  wounds. 

E.  Persistence  of  virus  —  may  persist  in  lesions  until  healed. 
Most  contagious  period  —  vesicular  stage. 

n.   PROPHYLAXIS. 

A.  Immunity.  Considerable  under  six  months  and  increased 
distinctly  after  five  years,  and  is  rather  marked  in  adult  life. 

B.  Asepsis.  Difficult  to  carry  on  in  practice,  the  disease  is  so 
contagious.     Principles  are  similar  to  scarlet  fever  and  diphtheria. 

C.  Isolation  —  should  be  insisted  on  as  early  as  possible  and 
continued  until  complete  healing  of  the  lesions  or  until  they  are 
entirely  dry. 

I.    Technic,  same  as  for  scarlet  fever  and  diphtheria,  p.  loi . 
Z).  Quarantine.     It  is  important  to  keep  exposed  persons  from 
contact  with  others  for  three  weeks  after  the  last  exposure. 
E.  Disinfection.     See  Scarlet  Fever,  p.  103. 

in.    TREATMENT. 

The  toxemia  of  varicella  is  of  slight  imporance.  Nephritis 
rarely  follows  the  disease.  The  chief  danger  is  from  infection  of 
the  skin  lesions  with  other  organisms  such  as  the  streptococcus, 
diphtheria  bacillus,  etc. 

A.  Toxemia.  Cold  sponging,  ice  caps,  rest  in  bed,  force  fluids, 
during  the  acute  stage  of  fever. 

B.  Local  lesions.  Careful  asepsis  is  essential  from  the  be- 
ginning. Daily  baths  with  soap  and  water  preferably  by  shower, 
drying  the  skin  with  clean  towels  and  anointing  with  boric  acid, 
vaselin  or  camphorated  oil   are  of  value.     Underclothes,  night 


[I29] 

clothes  and  sheets  should  be  kept  scrupulously  clean  and  changed 
daily.  At  times  it  may  be  advisable  to  use  weak  chlorinated 
baths.  Chlorinated  soda  is  especially  beneficial  for  small  areas 
of  secondar)^  skin  infection  and  may  be  followed  by  application 
of  ammoniated  mercurial  ointment. 

C.  Moutli  lesions.     Occasionally  many  lesions  occur  in  the 
mouth  which  may  require  very  careful  asepsis  and  cleansing. 

D.  Corneal  or  conjunctival  lesions  may  occur.     Treatment  of 
these  lesions  should  be  very  prompt  and  active  to  avoid  blindness. 


DIPHTHERIA. 

I.   MANNER  OF  SPREAD. 

A.  Exit  of  virus  —  chiefly  from  throat  and  nose  and  infected 
ear,  but  also  at  times  from  lesions  of  skin  as  cuts,  scratches, 
sinuses,  etc. 

B.  Viability  of  virus  —  may  survive  days,  weeks  or  some 
months,  but  under  ordinary  conditions  of  light  and  air,  dies  in  a 
few  days.     In  sunlight  dies  in  a  few  hours. 

C.  Manner  of  transfer  —  chiefly  by  direct  contact;  also  by 
indirect  contact  and  droplets.  Milk  —  the  only  known  food  to 
spread  disease.    No  gross  changes  in  infected  milk. 

D.  Points  of  entry  —  chiefly,  of  course,  nose  and  throat  and 
also  larv^nx  and  lungs;  rarely  eye  sack,  skin  of  genitals  especially 
in  puerperium. 

E.  Persistence  of  virus  —  persists  for  days,  weeks,  months,  or 
even  years  in  lesions  of  mucous  membranes,  such  as  enlarged  or 
diseased  tonsils.  Most  contagious  period  varies  with  extent  of 
mucous  membrane  lesions  and  quantity  of  discharge. 

n.  PROPHYLAXIS. 

A.  Immunity.  This  can  be  tested  by  Schick's  test,  ro  of  the 
minimum  lethal  dose  of  diphtheria  toxin  freshly  diluted  is  injected 
intracutaneously  into  arm.  A  positive  reaction  at  the  end  of  48 
hours  shows  a  red,  infiltrated  area  of  i  cm.  or  more  in  size,  the 
central  part  of  which  later  becomes  pigmented  and  finally  desqua- 
mates. The  whole  duration  of  the  lesion  is  one  or  more  weeks. 
Persons  having  a  positive  reaction  have  no  antitoxic  immunity. 


although  they  may  have  other  immunity.  Those  showing  no 
reaction  at  the  end  of  48  hours  are  immune.  The  immunity 
usually  persists  indefinitely.  False  reactions  usually  occur  early 
and  subside  quickly.  They  may  cause  an  error  in  reading  results. 
Control  may  be  secured  by: 

(i)  Heat  toxin  to  75°  C.  for  |  hour  and  use  as  before. 

(2)  Repeat  and  give  dose  of  antitoxin. 

(3)  Draw  blood  and  test  for  antitoxic  strength. 

Control  test  with  the  heated  toxin  should  usually  be  used, 
especially  in  adults. 

Readings  should  be  made  at  48  and  96  hours. 

1.  Passive.  1000  to  2000  units  of  antitoxin,  subcutaneously. 
For  immediate  need;  lasts  one  to  three  weeks  or  more. 

2.  Active.  Toxin  and  antitoxin  mixtures  are  used.  70  to 
85  per  cent  of  the  L  +  dose  of  toxin  mixed  with  one  unit  of  anti- 
toxin is  injected  at  intervals  of  one  week  for  three  doses.  An 
immunity  slowly  appears  in  1-4  mos.  that  lasts  years. 

3.  Local.  Secure  good  local  conditions  of  mucous  membrane. 
Remove  bad  teeth  or  roots,  diseased  tonsils  and  adenoids,  etc. 
Treat  diseased  gums  and  mucous  membranes  and  avoid  me- 
chanical or  chemical  injuries  to  the  mucous  membranes. 

B.  Asepsis. 

1.  Avoid  putting  fingers,  pencils,  pins,  etc.,  in  the  mouth  or 
to  the  nose. 

2.  Wash  the  hands  carefully  before  eating. 

3.  Do  not  use  common  drinking  cup  or  common  towel,  etc. 

4.  Avoid  kissing  on  lips. 

5.  Avoid  region  of  people  who  cough,  sneeze  or  spit. 

6.  Avoid  milk  handled  or  produced  under  poor  conditions, 
or  by  ill  persons,  and  avoid  public  dining  rooms  poorly  managed. 

C.  Isolation.  Isolation  is  of  great  value.  Prompt  recognition 
is  required  to  make  this  effective.  Missed  cases  also  must  be 
found  by  epidemological  studies,  and  culturing  suspects.  Isola- 
tion should  be  continued  until  virulent  diphtheria  bacilli  have 
been  absent  as  shown  by  cultures  for  at  least  three  days. 

I.    Technic  of  isolation.     See  under  Scarlet  Fever,  p.  loi. 

D.  Quarantine.  Quarantine  is  of  little  practical  value  as  cul- 
tures may  be  taken  in  exposed  persons,  and  if  found  to  be  negative, 


[  133  ] 

quarantine  need  not  be  continued.  Closing  of  schools  or  other 
places  of  assembly  is  unnecessary,  but  measures  should  be  taken 
to  discover  carriers  as  well  as  clinical  cases  among  those  who 
thus  come  together.  Schick's  test  is  of  great  value  in  finding 
those  who  are  susceptible  to  the  disease. 

III.   TREATMENT. 

The  chief  causes  of  death  in  diphtheria  are  toxic  action  on  brain 
centres  in  the  early  deaths,  toxic  degeneration  of  the  neuro- 
muscular tissues  of  the  heart  and  of  the  nerve  axis  cylinders  in  the 
deaths  after  one  week. 

In  the  laryngeal  cases,  strangulation  from  mechanical  obstruc- 
tion and,  more  commonly,  bronchopneumonia  are  the  chief 
causes  of  death. 

The  essentials  of  treatment  are  therefore  early  neutralization  of 
toxin  with  antitoxin  and  sufficiently  prompt  relief  of  laryngeal 
stenosis  by  intubation. 

A.  For  Tosemia. 

1.  Antitoxin. 

{a)   As  early  as  possible,  first  day  best. 

{]?)  Dose,  varying  with  severity  of  disease  and  mode  of 
administration.  2000  for  very  mild  to  100,000  units 
or  more  for  very  severe  cases.    See  antitoxin,  page  271. 

2.  General  eliminative  measures.  See  principles  of  treatment, 
page  75. 

B.  For  obstruction  of  breathing. 
I.    Antitoxin  as  early  as  possible. 

1.    Intubation  for  obstruction  at  larynx. 

{a)  Indications.  Stridor,  use  of  accessory  muscles  of  res- 
piration, restlessness,  dyspnea.  Relief  should  be  se- 
cured before  cyanosis  and  exhaustion  occur. 

3.  Tracheotomy. 

{a)    If  intubation  fails. 

(^)    For  obstruction  above  or  below  the  larynx. 

4.  Bronchoscopy. 

{a)  For  membranous  obstruction  low  down  in  trachea  or 
bronchi. 

C.  Local  treatment.    Of  slight  value  or  importance. 

I.    Cleansing  irrigations  for  the  throat.     Salme  solution,  boric 


[135] 

acid  solution,  or  Dobell's  solution  may  be  used  copiously  for 
cleansing  and  soothing  mucous  membranes  and  should  be  used 
as  warm  as  patient  can  tolerate  it.  Do  not  exhaust  the  patient 
by  excessive  attention. 

2.  Bacteriocidal  therapy  has  failed. 

3.  Soothing  applications  for  mechanical  protection  of  mucous 
membranes,  such  as  albolene  and  oily  sprays.  The  nose  may  be 
treated  in  this  way  or  by  instillations.  Irrigations  should  not  be 
used  in  the  nose. 

D.  Rest.  In  all  cases  in  which  toxemia  is  marked  the  patient 
should  be  kept  in  bed  for  three  to  six  weeks,  because  cardiac  or 
nerve  complications  may  occur  as  late  as  this. 

E.  Hygiene.     Sunshine,  fresh  air,  freedom  from  dust,  etc. 

F.  Diet.  Large  amounts  of  fluid.  Balanced  diet  easily 
digestible  and  sufficient  for  energy  requirements.  No  special 
dietic  indications  except  digestibility  and  water  content. 


IV.   TREATMENT  OF  COMPLICATIONS. 

I.  Cardiac.  Occurs  chiefly  in  the  first  three  weeks  of  the 
disease. 

(a)   Prevention.     Solely    by    early    antitoxin    in    sufficient 

amount. 
(l>)    Treatment. 

(i)  Horizontal  position.     Do  not  allow  the  head  or  body 
to  be  raised. 

(2)  Nothing  by  mouth  if  nausea  or  vomiting  is  present. 

(3)  Nutrient  enemata  and  salt  solution  or  glucose  solu- 
tions 5-10%  by  rectum  as  required  by  thirst. 

(4)  Morphine  subcutaneously  in  small  doses  for  sedative 
effect. 

(5)  Stimulationof  doubtful  value.     Caffeine  sodium  sali- 
cylate grains  one  to  five  ev.  4  hours,  subcutaneously. 

Note. —  The  essential  of  treatment  is  to  secure  the  highest 
degree  of  rest  and  avoidance  of  strain  on  the  heart.  The  dis- 
turbance is  self-limited,  rarely  lasting  more  than  one  week.  If 
the  demand  on  the  cardiac  function  is  kept  to  a  minimum  for  this 
period,  recovery  may  occur.     Myocardial  weakness  may  occur 


[i37] 

late  in  disease  and  require  careful  rest  but  it  is  of  small  importance 
compared  to  the  early  acute  cardiac  deficiency. 

2.  Diphtheritic  Paralysis. 

{a)   Prevention.     Solely   by   early   administration   of  anti- 
toxin in  sufficient  amounts. 
{b)    Treatment. 

(i)  Improve  circulation  locally  by  massage,  electricity 

and  passive  motion. 

(2)  Improve  general  condition.  Fresh  air,  sunshine, 
food,  iron  and  tonics. 

(3)  Antitoxin  is  of  no  value  after  the  paralysis  appears. 

3.  Otitis  Media.     See  under  Scarlet  Fever,  page  107. 

4.  Pneumonia.     See  under  Pneumonia,  page  153. 

5.  Chronic  "tubes";   chronic  obstruction  of  larynx  after  in- 
tubation. 

{a)   Prevention. 

(i)  Avoid  trauma  in  operation. 

(2)  Correct  size  tubes  to  avoid  undue  pressure. 

(3)  Shortest  reasonable  duration  of  wearing  tube. 
{b)    Treatment. 

(i)  Tracheotomy  to  avoid  laryngeal  irritation  or  injury 
if  obstruction  persists  four  weeks  without  improvement. 
(2)  After  healing  of  larynx  mechanical  dilatation  by 
means  of  tubes  or  dilators. 

6.  Cervical  Adenitis.     See  under  Scarlet  Fever,  p.  1 1 1 . 

7.  Serum  Disease. 

{a)  Urticaria.  Local  and  general  sedatives,  and  mild  cath- 
artics and  free  fluid  intake.  Adrenalin  i  to  1000  solu- 
tion, minims,  10  to  15  subcut.  Repeat  in  20  minutes 
if  necessary. 

{b)  Angio-neurotic  edema.  Treatment  unnecessary  and  in- 
effective. 

(<:)    Eythema  multiforme.    No  treatment  effective. 

{d)   Enlargement  of  lymph-nodes.    Apply  ice. 

{e)    Arthralgia.     Immobilize,  gaultheria  dressings,  salicylates. 

(/)  Arthus'  phenomenon,  a  local  cellulitis  at  point  of  in- 
jection of  antitoxin.     Poultices. 

{g)   Vomiting.     Stop  everything  by  mouth  for  a  time. 

(A)  Anaphylactic  shock. 


[i39] 

(i)  Prevention. 

{a)  Skin  test.  Scratch  skin  and  apply  a  little  serum. 
Local  reaction  of  urticarial  type  in  2  to  15 
minutes  shows  susceptibility.  In  this  case, 
antitoxin  cannot  safely  be  given  without  special 
precautions. 

(l?)  If  sensitized  to  horse  serum  bovine  serum  may  be 
used,  but  sensitization  to  this  should  also  be 
tested. 

(c)  If  patient  is  sensitized,  desensitization  may  be 

tried, 
(i)  Small  doses  starting  with  tot  cc.  to  two  cc, 
and  increase  the  dose  carefully  at  about  | 
hour  intervals. 

(d)  Paralyze   mechanism    of  shock,    i.e.,   bronchiole 

spasm, 
(i)  Atropine  in  full  dose  subcutaneously,  i  half 

hour  before  serum. 
(2)  Adrenalin  in  full  dose  at  the  same  time  as 
serum. 
(2)  Treatment.    Usually  death  is  too  rapid  to  allow  of 
treatment  being  used. 
(a)  Atropine,  full  doses. 
(F)  Adrenalin,  full  doses. 

(c)  Oxygen. 

(d)  Heat. 

V.   CARRIERS. 

1.  Remove  mucous  membrane  abnormalities,  if  possible. 
Enlarged  tonsils  and  adenoids,  foreign  bodies,  accessory  sinus 
disease,  carious  teeth,  etc. 

2.  Chemical  applications  have  been  of  very  doubtful  value  — 
silver  nitrate,  as  well  as  argyrol,  acetic  acid,  chromic  acid,  iodine, 
dichloramin  T,  etc.,  have  been  used. 

3.  "  Overriding,"  by  spraying  with  other  bacteria,  such  as 
the  staphylococcus  and  bacillus  bulgaricus  has  not  proved  of 
definite  value. 

4.  Powdered  kaolin  applications  at  short  intervals  has  not 
proved  its  value. 

5.  Vaccine  treatment  is  still  of  questionable  value. 


[i4i 


CHAPTER  V. 

ACUTE    INFECTIONS    OF    RESPIRATORY    TRACT. 

LOBAR  PNEUMONIA. 

Notes. —  An  acute  infectious  disease  of  multiple  etiology,  most 
commonly  caused  by  the  pneumococcus.  The  rate  of  the  pulse 
and  respiration  are  indices  of  toxemia. 

Mortality  commonly  due  to: 

nr.         .  \  (a)   Circulatory  disturbance, 

ioxemia  \  )i(.     ^     ^      • 

{b)    Asphyxia. 

{a)   Empyema. 

{b)    Pericarditis. 

{c)    Endocarditis. 


less  often  to 
2.   Complications 


PRINCIPLES  OF  TREATMENT. 

Secure  good  nursing  and  fresh  air. 

Eliminate  and  dilute  toxins. 

Watch  circulation. 

Stimulate  promptly  when  required. 

Prescribe  drugs  only  for  definite  reasons. 

Take  precaution  to  prevent  accident. 

Diet  suitable  to  case. 

Recognize  complications  prompdy. 

Use  serum  for  cases  of  Type  I,  p.  145. 

METHODS. 

1.  Eliminate  toxins  by  requiring  copious  ingestion  of  water, 
unless  the  heart  be  weak,  and  keep  the  bowels  clear.  Watch 
urinary  output  to  see  that  the  water  is  being  excreted. 

2.  Out-of-door  treatment  is  likely  to  benefit  robust  patients, 
but  the  old  and  feeble  are  likely  to  do  better  indoors.  Fresh  air 
is,  perhaps,  the  best  stimulant  in  pneumonia.  Sometimes  it 
diminishes  dyspnoea  and  promotes  comfort. 

3.  Note  the  outlines  and  sounds  of  the  heart  and  the  quality 
of  the  pulse  at  every  visit. 


[143] 

4-  Stimulation  is  indicated  (a)  if  the  quality  of  the  pulse  be 
poor,  (b)  if  it  becomes  irregular  or  (c)  if  the  rate  go  above  120. 

Irregularity  early  in  the  illness  is  less  apt  to  herald  danger  than 
that  developing  late.  (See  Circulatory  Disorders  of  Infectious 
Fevers  and  Sepsis,  p.  35.) 

5.  Dyspnoea  with  cyanosis  can  be  relieved  to  some  extent  by 
inhalation  of  oxygen  passed  through  absolute  alcohol.  It  should 
be  administered  with  an  apparatus  for  inhalation  and  not  simply 
through  a  tube. 

6.  Venesection  may  be  very  beneficial,  particularly  when  cya- 
nosis and  cardiac  embarrassment  develop  early. 

7.  Morphine  is  indicated  to  relieve  pleuritic  pain  when  a  tight 
swathe  fails  to  do  so.  Sleep  is  very  important  to  conserve  the 
strength  of  the  patient  and  morphine  may  be  used  to  obtain  it, 
especially  in  the  early  stages  of  pneumonia. 

Morphine  is  contraindicated  whenever  bronchial  secretion  is 
profuse,  because  it  checks  expectoration,  and  if  morphine  is  to  be 
used  in  the  later  stages  caution  is  necessary. 

8.  Diet  should  consist  of  food  that  requires  no  chewing  and 
that  is  easily  swallowed;  i.e.,  liquids,  and  soft  solids. 

The  amount  should  be  gauged  by  the  digestive  power  of  the 
individual,  but  the  usual  course  of  the  disease  is  so  short  that 
nutrition  is  seldom  important. 

Avoid  renal  irritants  and  gas-producing  foods. 

9.  Besides  the  complications  above  mentioned  look  out  for  a 
true  nephritis. 

10.  When  temperature  is  very  high  and  the  heart  doing  well, 
sponge  baths  may  be  used  to  reduce  the  fever. 

11.  Tympanites  may  require  treatment.  An  enema  of  i  oz. 
(or  30  mils.)  of  glycerin  undiluted  generally  acts  well. 

12.  Delirium: 

{a)   Push  eliminative  measures  to  reduce  toxemia. 

(■i^)  If  the  patient  is  emaciated,  try  to  improve  his  nutrition. 
Alcohol  by  mouth  may  be  beneficial  for  the  delirium 
of  exhaustion. 

{c)  As  a  palliative  for  active  delirium,  which  taxes  the 
patient's  strength,  morphine  gr.  1/6  (or  0.01080  gm.) 
or,  if  this  fails,  morphine  gr.  1/8  (or  0.00810  gm.)  and 
scopolamine  gr.  i/ioo  (or  0.00065  gm.)  may  be  used 


[145] 

subcutaneously.  Hypnotics  may  be  tried  cautiously 
but  circulatory  depressants  must  be  avoided. 
Caution.  Delirium,  even  when  slight,  may  be  dangerous. 
When  the  nurse  leaves  the  room  even  for  a  moment 
some  one  should  take  her  place  lest  the  patient  jump 
from  the  window.  No  razor  or  weapon  of  any  kind 
should  be  left  within  reach  of  the  patient. 


SERUM  THERAPY  OF  PNEUMONIA. 

By  Henry  M.  Thomas,  Jr.,  M.D. 

Note. —  Working  at  the  Hospital  of  the  Rockefeller  Institute, 
Cole  and  his  collaborators  developed  an  efficient  horse  serum  for 
the  treatment  of  pneumonia  caused  by  Type  I  pneumococcus 
and  established  its  value  in  shortening  the  course  of  the  disease 
and  greatly  reducing  its  mortality. 

The  methods  recommended  by  these  workers  for  the  administra- 
tion of  serum  have  proved  entirely  satisfactory  in  the  hands  of  a 
great  many  clinicians  and  form  the  basis  for  the  following  direc- 
tions. 

It  must  be  thoroughly  understood  that  serum  treatment  of 
pneumonia  is,  to  date,  limited  to  those  cases  in  which  the  disease 
is  caused  by  Type  I  Pneumococcus;  cases  in  which  the  etiologic 
organism  is  Pneumococcus  Type  II,  III,  IV  or  Streptococcus  or 
some  other  organism  have  given  no  evidence  of  benefit  derived 
from  any  serum  therapy.  Satisfactory  Type  I  antipneumococcus 
horse  serum  is  now  prepared  by  the  New  York  Board  of  Health, 
Massachusetts  Board  of  Health  and  several  commercial  firms 
from  which  it  may  easily  be  procured.  The  causative  organism 
of  the  disease  should  be  determined  with  the  greatest  possible 
haste  as  the  success  and  relative  efficiency  of  serum  treatment 
depends,  in  a  large  measure,  on  the  promptness  with  which  the 
serum  is  administered.  To  this  end  specimens  of  lung  sputum, 
urine,  and,  when  possible,  a  blood  culture  may  be  submitted  to  a 
bacteriological  laboratory  from  which  a  report  can  be  obtained  in 
from  six  to  twenty-four  hours.  If  the  presence  of  Pneumococcus 
Type  I  is  established,  treatment  should  be  begun  immediately. 


[147] 

METHODS 

A.   DETERMINATION  OF  POSSIBLE  SENSITIVENESS  TO  HORSE 

SERUM. 

Skin  Test  —  inject  0.02  mils,  of  a  i/io  solution  of  horse 
serum  in  normal  salt  solution  intradermally  on  the  dorsum 
of  the  forearm  sterilizing  the  skin  lightly  with  70%  alcohol. 
0.02  mil  normal  salt  solution  intradermally  3  inches  above  serves 
as  a  control.  No  reaction  or  merely  slight  erythema  around  the 
injection  at  the  end  of  30-60  minutes  indicates  absence  of  sensi- 
tiveness to  horse  serum.  A  positive  skin  test  as  evidenced  by  an 
urticarial  wheal  at  the  site  of  the  injection  of  horse  serum,  sur- 
rounded by  a  zone  of  erythema  necessitates  careful  densensitiza- 
tion.    This  may  be  done  as  follows: 

B.  DESENSITIZATION  OF  PATIENT  SHOWING  A  POSITIVE  SKIN  TEST. 

Starting  with  an  extremely  small  subcutaneous  dose  (0.025  mil.) 
of  horse  serum  the  amount  is  given  at  \  hour  intervals  doubling 
the  size  of  the  dose  at  each  injection  until  the  dose  reaches  i  mil. 
(The  injection  of  the  small  amounts  used  in  the  first  doses  is 
facilitated  by  the  preparation  of  a  i/io  solution  of  horse  serum  in 
normal  salt  solution.)  Subsequent  doses  may  be  given  intraven- 
ously starting  with  o.i  mil.  and  doubling  the  amount  at  each  \ 
hourly  injection.  If  symptoms  of  a  general  anaphylactic  reaction 
appear  these  should  be  controlled  by  the  administration  of 
adrenalin  hypodermically  and  after  they  have  completely  sub- 
sided a  dose  similar  to  that  producing  the  reaction  should  be  given 
and  the  gradual  increasing  of  the  amount  again  proceeded  with. 
When  25  mils,  of  serum  have  been  given  in  these  small  doses,  after 
a  lapse  of  4  hours,  50  mils,  may  be  given  followed  by  the  regular 
dose  6-8  hours  later.  This  procedure  is  rarely  necessary  —  some- 
thing less  than  2%  of  the  patients  requiring  it. 

C.  ROUTINE   DESENSITIZING   DOSE    IN   PATIENTS   WHO    SHOW  A 

NEGATIVE  SKIN  TEST. 

Method:  Inject  subcutaneously  i  mil.  of  horse  serum,  thus 
minimizing  any  serum  reaction  which  may  occur  in  patients  who 
have  shown  negative  skin  tests.     After  i  hour  proceed. 


[up] 

D.  ADMINISTRATION  OF  TYPE  I  ANTIPNEUMOCOCCUS  SERUM. 

Only  persons  familiar  with  the  technic  of  intravenous  medica- 
tion should  perform  this  step.  The  serum,  which  is  usually  put 
up  in  bottles  containing  loo  mils,  may  be  transferred  into  a  sterile 
intravenous  set  such  as  is  used  for  the  administration  of  arsphena- 
mine  or  may  be  aspirated  directly  from  the  bottle  by  means  of  a 
rubber  tube,  and  20  mils,  syringe  and  injected  into  the  vein  with 
the  use  of  a  three-way  stop  cock.  Care  should  be  taken  not  to 
inject  the  sediment,  which  always  settles  to  the  bottom  of  the 
bottle,  as  this  may  add  to  the  severity  of  the  reaction.  The 
serum,  which  is  kept  in  a  refrigerator  to  maintain  its  potency,  is 
heated  to  body  temperature  by  emersing  the  bottle  in  hot  water 
just  before  administering  it. 

Any  anaphylactic  reaction  which  may  occur  will  make  itself 
evident  by  the  end  of  10-20  minutes.  For  this  reason  a  small 
amount  (10-15  mils.)  should  be  injected  slowly  during  the  first 
15-20  minutes  so  that  the  treatment  may  be  temporarily  inter- 
rupted at  the  first  appearance  of  symptoms.  If  the  patient  shows 
no  evidence  of  a  reaction  such  as  increased  pulse  rate,  difficulty 
in  breathing,  flushing  of  the  face  and  chest,  sensation  of  com- 
pression over  the  chest,  sneezing,  cyanosis,  sweating,  marked 
anxiety,  urticaria,  or  edema  of  the  eye-lids  or  lips,  the  remaining 
80  or  90  mils,  may  be  more  quickly  injected  in  15-20  minutes. 
If,  on  the  other  hand,  one  or  more  of  these  symptoms  occurs  the 
injection  should  be  discontinued  for  10-20  minutes  until  they  have 
subsided,  when  the  treatment  may  be  completed.  Should  the 
reaction  become  more  severe  rather  than  quickly  clearing  up,  the 
injection  had  better  be  suspended  for  an  hour  or  two  and  steps 
taken  to  check  the  symptoms.  This  is  best  accomplished  by 
hypodermic  doses  of  adrenalin  (0.5  mil.  to  0.7  mil.  of  i  :iooo  sol.) 
or  atropine  sulphate  (0.5  mg.)  or  both. 

E.   NUMBER  AND  FREQUENCY  OF  TREATMENTS. 

In  an  adult  100  mils,  of  serum  should  be  given  every  eight  hours 
until  the  rectal  temperature  has  fallen  and  remains  below  102°  F. 
Children  may  require  relatively  smaller  doses.  Following  the 
first  drop  in  temperature  a  subsequent  rise  should  be  watched  for 


[151] 

and  if  it  occurs  without  complications  to  account  for  it,  further 
serum  treatment  should  be  employed.  In  cases  treated  on  the 
second  or  third  day  of  the  disease,  one  to  three  injections  usually 
suffice.  Where  the  treatment  is  begim  later  than  the  third  day 
as  many  as  five  or  six  injections  are  occasionally  required.  No 
success  is  to  be  expected  from  intravenous  treatment  of  cases 
suffering  from  complications  such  as  otitis  media,  meningitis  or 
empyema.  Direct  application  of  the  serum  to  the  affected  area 
may,  in  some  instances,  lead  to  improvement. 


F.   SERUM  REACTIONS. 

I.    Anaphylactic  Reactions. 

The  common  symptoms  encountered  in  this  form  of  reaction 
have  been  enumerated  under  Section  III. — They  occur  ven,^  shortly 
after  the  intravenous  administration  of  serum  and  rarely  if  ever 
occur  later  than  30  minutes  after  the  treatment  is  begun.  If 
disregarded  and  nothing  done  to  avoid  or  prevent  it,  this  reaction 
may  easily  prove  fatal. —  If  care  is  taken  as  outlined  above  to 
determine  the  question  of  sensitiveness  and  to  desensitize  the 
patient  according  to  the  individual  necessity-,  and  if  the  first  dose 
is  administered  slowly,  no  untoward  effects  should  ever  be  en- 
countered. Obviously,  it  is  exceedingly  important  to  avoid  any 
severe  anaphylactic  reaction  in  a  patient  already  heavily  taxed 
by  a  serious  infection. 

II.    Thermal  Reaction. 

Twenty  minutes  to  one  hour  after  the  injection  of  serum  a  more 
or  less  violent  chill  associated  with  cyanosis  and  slight  difficulty  in 
breathing  may  occur.  It  lasts  usually  about  20-30  minutes  and 
needs  little  treatment  other  than  the  usual  care  of  patients  having 
a  chill.  The  temperature  rises  1-3  degrees  during  the  chill  and 
frequently  falls  to  normal  after  it,  where  it  may  remain  or  may 
climb  again  to  its  original  height.  Little  or  no  importance  is 
attached  to  this  phenomenon  and  no  adequate  explanation  of  its 
occurrence  following  one  injection  and  not  following  an  identical 
preceding  or  subsequent  one  has  been  advanced. 


[i53l 

in.   Serum  Disease. 

In  a  large  majority  of  cases  receiving  serum  certain  symptoms 
make  themselves  apparent  7-14  days  after  the  last  dose  of  serum. 
These  symptoms  occurring  singly  or  in  varying  combinations  have 
become  known  as  serum  sickness.  They  consist  in  fever  (eleva- 
tion of  1-5  degrees)  skin  eruption  (urticaria  or  erythema  which 
may  simulate  scarlet  fever  or  rubella  or  rubeola),  local  edema  of 
the  skin,  headache,  bone-ache,  enlargement  of  the  lymph  glands 
and  transient  albuminuria.  Of  these  symptoms  the  ones  most 
commonly  encountered  and  also  the  most  annoying  to  the  patient 
are  the  urticaria  and  the  bone-aches. 

The  urticaria  may  be  temporarily  relieved  by  local  applications 
of  calomine  lotion  or  95%  alcohol  gently  daubed  on.  Adrenalin 
in  hypodermic  doses  of  0.6-1  mil.  causes  the  eruption  to  disappear 
and  gives  relief  from  the  itching  for  a  period  of  several  hours. 
The  urticaria  may  last  for  a  few  hours  or  for  several  days. 

The  headaches  and  joint  aches  are  satisfactorily  controlled  by 
salicylates. 

If  albuminuria  occurs  the  patient  should  be  placed  on  a  nephritic 
diet  until  it  has  disappeared  but  this  complication  is  a  rare  one. 

Care  should  be  taken  not  to  overlook  some  complication  of  the 
pneumonia  while  laboring  under  the  belief  that  all  the  symptoms 
are  due  to  serum  disease. 

The  ordinary  therapeutic  measures  used  in  the  care  of  pneu- 
monia patients  must,  of  course,  be  carried  out  in  conjunction  \vith 
the  serum  treatment  although  the  use  of  senim  will  often  greatly 
reduce  the  need. 

BRONCHO-PNEUMONIA. 

Treatment  is  essentially  the  same  as  for  lobar  pneumonia  ex- 
cept that  the  disease  generally  runs  a  milder,  but  longer,  course. 
Nutrition,  therefore,  is  more  important. 

Bronchitis  is  often  associated  with  broncho-pneumonia,  and 
when  this  is  the  case,  expectorants  may  be  of  service  during  con- 
valescence.   The}^  are  contraindicated  in  the  acute  stage. 

The  broncho-pneumonia  of  influenza  may  be  very  severe  in 
character  (see  Influenza,  p.  169). 


[155] 

BRONCHITIS. 
ETIOLOGY. 

Acute  bronchitis  commonly  follows  infections  of  the  upper 
respiratory  tract  and  especially  infections  by  the  pneumococcus 
or  influenza  bacillus.  It  occurs  symptomatically  in  some  in- 
fectious diseases,  e.g.,  typhoid  and  measles. 

Chronic  bronchitis  is  often  associated,  in  old  or  middle-aged 
persons,  with  slight  cardiac  insufficiency  or  with  emphysema. 
Rarely,  gout  is  a  factor. 

Excessive  inhalation  of  tobacco  smoke  may  be  a  factor  in  the 
production  or  continuance  of  bronchitis. 

DIAGNOSIS. 

Acute  or  chronic  bronchitis  may  be  simulated  by  tuberculosis 
and,  therefore,  sputum  examination  is  imperative.  Many  cases 
of  bronchiectasis  following  influenza  are  wrongly  diagnosed  as 
bronchitis  or  as  phthisis. 

ACUTE  BRONCHITIS:  TREATMENT. 

I.  When  there  are  constitutional  symptoms  the  patient  should 
keep  warm  and  avoid  change  of  temperature  by  staying  indoors. 
1.   If  there  is  fever,  bed  may  be  advisable  or  necessary. 

3.  Bronchial  secretion  must  be  expectorated,  but  unproductive 
cough  should  not  be  allowed  to  fatigue  the  patient  or  to  prevent 
sleep. 

If  the  cough  comes  from  pharyngeal  irritation  fp.  165),  lozenges 
may  suffice  to  check  it;  if  from  the  larynx  or  trachea,  steam  in- 
halations (p.  167)  may  be  serviceable.  If  necessary  for  relief  ot 
cough  codeine  sulphate  \  gr.  (or  0.016  gm.)  or  diacetylmorphine 
hydrochloride  t2  gr.  for  0.005  grn-)  ^^y  be  prescribed  for  use 
in  the  afternoon  or  at  night.  Morning  cough  is  generally  needed 
to  clear  the  lungs.     It  can  be  promoted  by  a  hot  drink. 

4.  Substernal  distress  or  pain,  see  tracheitis,  p.  169. 

5.  Expectorants  are  contraindicated  during  the  acute  stage  of 
bronchitis  because  they  irritate  the  inflamed  mucous  membrane. 
They  may  be  used  during  convalescence,  at  which  time  the  ex- 
pectoration is  often  tenacious  and  difficult  to  raise. 


[157  J 

6.  Several  weeks  are  generally  required  for  complete  recovery, 
but  when  the  patient  feels  well  he  may  be  allowed  to  resume  his 
occupation.  Smoking  and  cold  bathing  should  be  resumed 
cautiously  and  unnecessary  exposure  should  be  avoided  as  long  as 
expectoration  persists. 

CHRONIC  BRONCHITIS:  TREATMENT. 

1.  Expectorants  are  generally  beneficial,  particularly  potas- 
sium iodide  in  the  dose  of  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.),  t.i.d.^ 
or  in  the  form  of  syrup  of  hydriodic  acid  one  dram  (or  3.70  mils.) 
in  water  three  to  five  times  a  day. 

2.  When  there  is  any  sign  of  cardiac  insufficiency,  appropriate 
stimulants  are  indicated.  For  slight  insufficiency  the  Compound 
Squill  Pill  may  act  well  both  as  a  heart  stimulant  and  as  an  ex- 
pectorant. The  usual  dose  is  from  6  to  9  pills  daily.  They  should 
be  freshly  prepared.  Systematic  cardiac  treatment  may  be  re- 
quired. 

3.  An  equable  and  warm  climate  may  promote  comfort,  espe- 
cially for  elderly  persons. 

4.  If  the  presence  of  bronchiectasis  be  suspected  treat  the  case 
as  one  of  bronchiectasis. 

5.  Acute  exacerbations  of  chronic  bronchitis  may  be  treated 
much  as  is  acute  bronchitis,  but  severe  symptoms  generally  indi- 
cate that  some  form  of  pneumonia  has  developed,  and  treatment 
should  be  regulated  accordingly  (p.  153). 

6.  Codeine  sulphate  or  heroine  hydrochloride  should  not  be 
used  consecutively  over  long  periods  on  account  of  the  danger  of 
forming  a  habit. 

7.  The  bronchitis  of  overfed  patients  is  often  benefited  by  de- 
pletion.    Exclude  gout  as  a  factor. 

8.  Excessive  cigarette  smoking  may  aggravate  the  condition, 
or  be  an  important  factor  in  its  causation. 

BRONCHIECTASIS. 

Note. —  The  disease  is  chronic,  lasting  for  thirty  years,  more 
or  less.  The  patient  may  be  subjected  to  recurring  attacks  of 
broncho-pneumonia,   or   of  hemoptysis.     Many   patients   have 


[159] 

emphysema  or  asthma,  f  The  condition  is  often  diagnosed 
wrongly  as  bronchitis  or  tuberculosis.  Many  cases  are  traceable 
to  influenza.  The  sputum,  typically,  is  abundant,  purulent, 
greenish,  nummular,  can  be  raised  at  will  by  coughing,  and  often 
contains  abundant  influenza  bacilli  as  well  as  various  other 
organisms.  Repeated  examinations  may  be  necessary  to  demon- 
strate the  influenza  bacilli.  The  cavities  may  be  localized  in  one 
lobe  or  disseminated  throughout  both  lungs.  Nutrition  is  gener- 
ally good.  As  the  physical  examination  may  show  only  a  few 
rales,  the  diagnosis  must  rest  on  the  history,  the  character,  and 
the  amount  of  the  sputum. 


TREATMENT. 

No  method  yet  devised  off"ers  hope  of  cure. 
Efforts  must  be  directed  to  relieving  the  patient  as  far  as 
possible  from  unpleasant  symptoms. 

1.  Teach  the  patient  to  drain  his  cavities  on  rising  in  the  morn- 
ing, and,  if  necessary,  once  or  twice  later  in  the  day.  This  can  be 
facilitated  by  taking  a  drink  of  hot  water,  tea  or  coffee  at  such 
times.  Potassium  iodide  fr.  5  to  lo  grs.  (or  0.3  to  0.65  gm.)  or 
other  expectorants  may  be  used  if  the  secretion  be  too  viscid  to 
come  up  readily. 

Gomenol  *  min.  3  (or  0.2  mils)  in  capsule  t.i.d.  is  sometimes  of 
value. 

2.  Avoid  sedatives  because  they  check  free  expectoration. 
The  material  then  decomposes  in  the  cavities  and  gives  a  foul 
odor  to  the  breath  and  to  the  sputum. 

3.  In  extreme  instances  of  retained  secretion  the  condition 
with  its  dyspnea  and  cyanosis  may  simulate  bronchial  asthma. 
A  differential  diagnosis  can  be  made  from  history  and  sputum. 
An  emetic  will  give  immediate  relief  by  clearing  the  lungs. 

4.  Most  of  these  patients  are  better  in  warm  weather.  A 
uniformly  mild  climate  may  relieve  but  cannot  cure. 

5.  Sputum  must  not  be  swallowed  because  diarrhea  may  result. 

6.  Foul-smeUing  sputum  means  inefiicient  drainage  of  cavities. 


t  Empyema,  abscess,  arthralgia,  or  pneumothorax  occur  in  rare  instances. 
*  A  preparation  of  Oleum  cajuputi  (U.S.). 


[i6i] 

The  odor  can  be  ameliorated  by  the  use  of  3  min.  (or  0.2  mils.) 
of  Eucalyptol  on  a  lump  of  sugar  several  times  daily. 

7.  When  the  disease  is  localized  in  one  lobe  of  the  lung  the 
chance  of  relief  by  surgical  means  may  be  considered. 


ACUTE  INFLAMMATION  OF  THE  UPPER 
RESPIRATORY  TRACT. 

Revised  by  Gerald  Blake,  M.D. 

Etiology:  infectious  in  most  instances.  The  pneumococcus, 
streptococcus,  staphylococcus,  influenza  bacillus,  diphtheria 
bacillus,  micrococcus  catarrhalis  or  other  bacteria  may  be  causa- 
tive. Among  predisposing  factors  lowered  physical  resistance  and 
exposure  to  cold  are  important. 

Course  of  Disease.  Inflammation  generally  begins  in  the 
nasopharynx  (pharyngitis).  It  usually  extends  within  a  few  days 
to  the  nasal  mucous  membrane  (coryza)  and  often  to  the  tonsils 
(tonsillitis)  or  larynx  (laryngitis).  The  severity  and  extent  of 
the  inflammation  depends  chiefly  on  the  kind  and  virulence  of 
the  infecting  organism  and  on  the  resistance  of  the  patient. 

Complications  and  Sequelae. 


I. 

Bronchitis. 

8. 

Bronchiectasis. 

2. 

Otitis  media. 

9- 

Septicemia. 

3- 

Peritonsillar  abscess. 

10. 

Meningitis. 

4- 

Lobar    or    broncho- 

II. 

Peritonitis. 

pneumonia. 

12. 

Inflammation  of  the  antrum. 

5. 

Arthritis. 

frontal,  ethmoidal  or  sphe- 

6. 

Endocarditis. 

noidal  sinuses. 

7. 

Glomerulo-nephri  tis . 

Diagnosis.  Exclude  whooping-cough,  scarlet  fever,  measles 
and  diphtheria.  The  diagnosis  of  diphtheria,  in  some  cases,  can 
be  made  by  culture  only.  Therefore  the  safest  plan  is  to  take  a 
culture  in  every  case  of  inflammation  of  the  throat  and,  if  the 
report  be  negative  but  the  signs  suggestive  of  diphtheria  to  take 
another  culture. 


[i63] 

PROPHYLAXIS. 

1.  If  there  is  a  reasonable  probability  that  the  symptoms  are 
due  to  diphtheria  or  to  one  of  the  exanthemata  isolate  the  patient 
provisionally. 

2.  If  the  clinical  evidence  points  to  diphtheria  administer 
antitoxin  (p.  271)  to  the  patient  without  waiting  for  the  report  on 
the  culture;  or  even  if  the  first  culture  be  negative. 

Prophylactic  inoculation  of  all  persons  exposed  to  diphtheria 
should  be  insisted  on. 

3.  Patients  having  infections  of  the  respiratory  tracts  should 
cover  the  mouth  on  coughing  or  sneezing. 

4.  Good  ventilation  of  rooms  occupied  by  the  patient  reduces 
risk  of  contagion. 

TREATMENT  APPLICABLE  IN  GENERAL. 

1.  Keep  the  patient  in  a  warm,  but  well-ventilated  room  at  a 
uniform  temperature. 

2.  Promote  rest  and  sleep,  using  sedatives  or  hypnotics  when 
needed. 

3.  Move  bowels,  at  outset,  by  enema  or  cathartic  unless  they 
have  been  acting  freely. 

4.  Allay  unproductive  or  irritating  cough  by  lozenge  or  seda- 
tive. 

5.  Avoid  local  irritation  by  tobacco  or  concentrated  liquor. 

6.  Cleanse  mucous  membrane  frequently,  and  soothe  inflamma- 
tion by  means  of  a  non-irritating  gargle.  Warm  water,  with  or 
without  salt  or  sodium  bicarbonate  in  it,  or  Liquor  antisepticus 
alkalinus  (N.F.)  may  be  used  diluted  with  3  parts  of  warm  water. 

7.  Antipyretics,  e.g.^  phenacetin  fr.  5  to  10  grs.  (or  0.3  to  0.65 
gm.),  with  caffeine  citrate  i  gr.  (or  0.065  g^i-ij  or  salicyl  prepara- 
tions (p.  00),  may  alleviate  discomfort  especially  if  there  be  fever, 
malaise  or  pain. 

8.  Food  should  be  readily  digestible  and  easy  to  swallow. 

Abortive  Treatment.  This  can  be  effective  in  the  early  stages 
only,  and  seldom  even  then.  The  following  measures  may  be 
tried. 

1.  Cleansing,  non-irritating  gargle. 

2.  Hot  bath  before  retiring,  or 


[i65] 

3.  Hot  drink  on  retiring  to  produce  sweating. 

4.  Early  to  bed,  and  hypnotic  unless  sleep  comes  quickly. 

5.  Catharsis  by  calomel  or  saline. 

6.  The  patient  should  dress  in  a  warm  room  and  avoid  cold 
bathing  on  the  following  morning. 


METHODS  OF  TREATMENT. 
ACUTE  PHARYNGITIS. 

1.  Cleansing  gargle  every  four  hours. 

2.  Oil  spray  *  after  gargle  to  protect  and  soothe  mucous  mem- 
brane. 

3.  Check  cough  with  lozenges  when  possible.  Otherwise  use 
codeine  or  diacetylmorphine. 

4.  Cases  with  constitutional  symptoms  of  considerable  severity 
may  occur.     "  Lateral  Pharyngitis  "  is  typical  of  this  group. 

"  Lateral  Pharyngitis."  Characterized  by  marked  general 
toxic  reaction  associated  with  redness  and  swelling  of  the  folds  of 
lymphoid  tissue  at  the  sides  of  the  pharynx.  The  severity  of  the 
general  reaction  is  out  of  all  proportion  to  the  mildness  of  the  local 
inflammation.     Due  to  the  pneumococcus. 

Treatment  consists  in  general  measures  of  rest,  catharsis,  use  of 
salicylates  for  relief  of  pain  and  reduction  of  temperature. 

Local  treatment.  Touching  the  pharynx  with  50%  sol.  silver 
nitrate  is  effective  in  relieving  local  inflammation. 

CORYZA. 

Keep  the  nose  as  free  as  possible  from  secretion. 

Irrigation  of  the  nose  with  an  alkaline  solution  often  gives  much 
relief,  but  some  physicians  believe  that  this  practice  may  lead  to 
inflammation  of  the  frontal  sinus  or  middle  ear.  An  oil  spray  * 
may  be  used  to  free  the  nasal  passages. 

If  the  secretion  be  profuse  and  watery,  its  quantity  can  be  di- 
minished by  using  wo-  gr.  (or  0.00032  gm.)  of  atropine  sulphate  and 
repeating  it  in  fr.  4  to  6  hours  s.o.s.    Atropine  is  contraindicated 


*  Petrolatum  liquidum  will  serve.  Menthol  5  grs.  (or  0.3  gm.)  or  Eucalyptol  5  min. 
(or  0.3  mils.)  or  both  can  be  added  per  oz.  (or  30  mils.)  of  liquid  petrolatum.  The 
De  Vilbiss  atomizer  is  good. 


[i67] 

when  secretion  is  viscid  or  tenacious.  Excessive  dosage  causes 
dryness  of  the  throat,  increases  discomfort,  and  may  cause  severe 
poisoning. 

Atropine  can  be  used  in  the  form  of  Tr.  of  belladonna  leaves; 
dose  from  lo  to  30  min.  (or  0.6  to  1  mils.). 

ACUTE  TONSILLITIS. 

1.  Take  a  culture. 

2.  Whereas  the  constitutional  symptoms  are  apt  to  be  severe 
it  is  generally  advisable  to  keep  the  patient  in  bed. 

3.  Prescribe  cleansing  gargle  to  be  used  every  four  hours.  The 
tonsils  may  be  painted  daily  with  argyrol,t  fr,  10  to  20  per  cent  in 
watery  solution  (or  a  spray  of  20%  argyrol  in  water  may  be  used 
after  gargling. 

4.  hxi  oil-spray,*  used  after  gargling,  may  give  some  relief  by 
allaying  irritation. 

5.  An  ice-bag  collar  may  help  much  to  relieve  pain  in  the 
throat. 

6.  The  diet  must  be  easy  to  swallow.  Cold  drinks  may  be 
grateful. 

7.  Occasional  doses  of  phenacetin  or  of  a  salicyl  preparation 
(p.  287)  may  be  beneficial  for  fever,  malaise  or  pain. 

8.  Opiates  or  hypnotics  are  indicated  sometimes. 

9.  Salicylate  (p,  287)  in  large  doses  acts  well  in  some  cases  of 
tonsillitis  having  slight  articular  symptoms  due  probably  to 
streptococcus  infection. 

10.  Note  at  first  visit  the  size,  position  and  sounds  of  the  heart, 
and  the  presence  or  absence  of  murmurs.  Watch  for  any  change 
and  before  discharging  the  patient,  determine  whether  the  heart 
or  the  kidneys  have  suffered. 

ACUTE  LARYNGITIS    ■ 

1.  Scarification,  intubation  or  even  tracheotomy  may  be  re- 
quired for  edema. 

2.  Steam,    plain    or    medicated,    ordinarily    gives    rehef.     It 

tu.  s.  t. 

*  Petrolatum  liquidum'will  serve.  Menthol  5  grs.  (or  0.3  gm.)_or  Eucalyptol  5  min. 
(or  0.3  mils.)  or  both  can  be  added  per  oz.  (or  30  mils.)  of  liquid  petrolatum.  The 
De  Vilbiss  atomizer  is  good. 


[169] 

should  be  used  every  few  hours  or  as  desired.  The  steam  can  be 
inhaled  from  the  mouth  or  from  a  pitcher  containing  boiling  water. 
To  the  water  may  be  added  i  drach.  (or  4  mils.)  of  compound 
tincture  of  benzoin.  A  steam  atomizer  which  can  be  used  to  spray 
oil  and  steam  together  is  still  better.  For  very  sensitive  diroats 
the  steam  and  oil  may  act  better  without  other  ingredients,  but 
Menthol  5  grs.  (or  0.3  gm.),  or  Eucalyptol  5  min.  (or  0.3  mils.), 
or  both  can  be  added  per  oz.  (or  30  mils.)  of  Liquid  petrolatum. 

Excessive  dryness  of  the  air  of  the  room  is  harmful.  It  can  be 
mitigated  by  allowing  steam  to  escape  constantly  from  kettle  or 
chafing  dish. 

3.  Cough  must  be  checked  and  talking  minimized. 

4.  Smoking  is  especially  harmful  as  a  rule. 

ACUTE  TRACHEITIS. 

Treatment  as  for  laryngitis  may  suffice. 

A  flaxseed  or  mustard  poultice  *  for  the  upper  chest  or  steam 
inhalation  may  help  to  relieve  substernal  distress.  Mustard 
should  be  avoided  if  resulting  pigmentation  would  contraindicate 
its  use.  "  Gomenol  jujubes  "  f  taken  every  3  to  6  hours  may 
relieve. 

INFLUENZA. 

By  Gerald  Blake,  M.D. 

A^o^e. —  The  etiology  is  in  dispute,  but  it  seems  probable  that 
the  initial  disease  is  caused  by  the  influenza  bacillus,  and  that 
pulmonary  and  some  other  complications  are  attributable  to 
secondary  infections  in  which  a  variety  of  organisms  may  play  a 
part.  Among  these  may  be  mentioned  streptococcus  hemolyticus, 
staphylococcus  aureiis,  pneumococcus  and  micrococcus  catar- 
rhalis. 

TYPES  OF  INFLUENZA. 

I.   Respiratory. 

A.  Mild  like  severe  coryza. 

B.  Bronchitic. 

C.  Bronchopneumonic. 


*  See  textbook  on  nursing. 

t  A  preparation  of  Oleum  cajuputi  (U.S.). 


[171] 

II.    Gastrointestinal. 

D.  Gastric. 

E.  Intestinal. 

Certain  symptoms  are  common  to  both  types,  viz:  sudden 
onset,  prostration,  fever,  headache,  pain  in  back  and  extremities. 

PROPHYLAXIS. 

1.  Isolation  to  prevent  spreading  of  the  contagion  should  be 
carried  out  in  all  cases. 

2.  The  use  of  masks  and  gowns  is  advisable  for  doctors  and 
nurses.  Care  should  be  taken  that  the  mask  is  changed  at  each 
visit,  or  that  some  mark  should  be  made  on  the  inner  surface  of 
the  mask  so  as  to  prevent  the  mask  being  put  on  inside  out  at 
subsequent  visits.  The  application  of  Boric  Acid  Ointment 
inside  the  nostrils  is  probably  of  value  in  preventing  the  con- 
tagion reaching  the  mucous  membranes. 

TREATMENT. 

It  is  of  the  utmost  importance  that  the  patient  go  to  bed  im- 
mediately at  the  onset  of  infection,  and  remain  in  bed  until  re- 
covery is  complete  in  order  to  prevent  complications,  and  to 
conserve  strength. 

General  principles  of  treatment  as  of  Acute  Infectious  Diseases, 
page  (75) 

A.    Mild  Respiratory  Type. 

Characterized  by  the  symptoms  of  acute  infection  of  the  upper 
respiratory  tract;  corv^za,  pharyngitis,  tonsillitis.  Epistaxis  is 
common  and  may  be  repeated  and  severe. 

General  principles  of  treatment  as  of  Acute  Infections  of 
Respiratorv^  Tract,  page  (161) 

1 .  Salicylates  may  be  given  for  the  control  of  pain  and  reduc- 
tion of  temperature,  but  should  be  used  cautiously  because  of 
depressant  action  on  heart. 

2.  Local  treatment  as  of  Acute  Pharyngitis,  page  (165) 

3.  Epistaxis  is  best  controlled  by  an  anterior  plug  of  gauze 
wrapped  in  Cargile  membrane.     Care  should  be  taken  to  dip  the 


L 173  J 

plug  and  forceps  in  hot  water  just  before  insertion  in  order  to 
prevent  the  plug  from  adhering  to  the  forceps.  Posterior  plugging 
of  nares  is  seldom  necessary. 

B.  Bronchitic  Type. 

Characterized  by  a  persistent  cough,  substernal  pain  and  signs 
of  bronchitis. 
Treatment  as  of  xA.cute  Bronchitis,  page  155. 

1.  Expectorants  are  probably  harmful  in  the  early  stages,  and 
of  little  value  in  the  later  stages  of  the  bronchitis. 

2.  A  change  from  a  damp  to  a  dry  climate  is  sometimes  the 
only  measure  which  seems  effective  in  clearing  up  the  persistent 
cough. 

C.  Bronchopneumonic  Type. 

Characterized  by  symptoms  of  bronchopneumonia. 

1.  The  foci  may  be  numerous  and  tend  to  spread;  there  is  a 
relatively  low  rate  of  pulse  and  respiration,  and  evidences  of 
severe  toxemia. 

2.  The  sputum  may  contain  much  blood. 

3.  Involvement  of  the  pleura  is  comparatively  rare,  although 
the  physical  signs  are  confusing, 

4.  Cyanosis  and  dyspnea  are  indications  of  the  severity  of  the 
toxemia.     It  is  particularly  fatal  in  pregnant  women. 

Serum  Treatment :  The  blood  should  be  obtained  from  a  patient 
convalescent  from  influenza  broncho-pneumonia  whose  tempera- 
ture has  been  normal  from  eight  da)'s  to  six  weeks,  preferably  ten 
days,  and  who  has  a  negative  Wassermann  test.  Five  hundred 
mils,  of  blood  may  be  taken  twice  at  an  interval  of  one  or  two  days. 
The  blood  is  received  in  a  sterile  bottle  which  is  then  placed  in  an 
incubator  at  body  temperature  for  one  hour.  It  is  then  put  in  a 
refrigerator  for  five  or  six  hours,  or  over  night.  The  serum  is  then 
decanted  and  centrifugalized  to  remove  bits  of  fibrin  or  red  cells, 
after  which  serum  obtained  from  all  donors  is  mixed.  This 
"  pooling  "  of  serum  is  desirable  as  providing  serum  from  severe 
as  well  as  light  cases.  To  the  pooled  serum  is  added  one  and  five 
tenths  per  cent  tricresol  (made  up  in  physiologic  sodium  chloride 
solution)  in  the  proportion  of  20  mils,  to  every  100  mils,  of  pooled 
serum.  The  serum  is  then  stored  in  120  mil  amounts.  Such 
serum  is  effective  up  to  six  weeks  after  storage. 


[175  J 

Intravenous  injection  of  120  mils,  of  the  serum,  heated  to  shghtly 
above  body  temperature,  is  performed  and  may  be  repeated  on  the 
following  day,  and  again  on  the  third  day  if  necessary.  When 
effective,  there  is  a  fall  of  temperature  either  by  crisis  or  lysis 
usually  within  forty-eight  hours.  The  sooner  serum  treatment 
is  started  after  the  diagnosis  has  been  made  the  more  reason  to 
hope  for  good  results  from  its  use.* 

General  treatment  is  that  of  Lobar  Pneumonia,  page  141. 

D.  Gastric  Type. 

Characterized  by  severe  epigastric  pain  and  vomiting.  There 
may  be  spasm  of  the  abdominal  muscles.  An  inflammatory 
process  is  excluded  by  the  presence  of  general  symptoms  of  in- 
fluenza and  the  low  leukocyte  count. 

General  treatment  is  that  of  Acute  Infectious  Disease,  page  75. 

Symptomatic  treatment  as  of  Acute  Indigestion,  p.  221. 

Alcohol  by  mouth  may  be  of  distinct  value  where  other  food  is 
not  retained. 

E.  Intestinal  Type. 

Note. —  Exclude  dysentery  and  typhoid  by  laboratory  tests. 
Characterized  by  diarrhea,  general  abdominal  discomfort,  loss 
of  appetite,  etc. 
General  treatment  as  of  acute  Infectious  Diseases,  page  75. 
Symptomatic  treatment  as  of  simple  diarrhea,  page  225. 

COMPLICATIONS  AND  SEQUELAE. 

I.   Empyema  is  rare,  and  when  present  is  usually  encapsulated 
or  interlobar.    When  suspected,  thoracentesis  should  be  done, 
and  if  without  result  should  be  repeated  at  another  point. 
T^  1.   Bronchiectasis  is  a  common  sequel. 
r*HGeneral  treatment  is  that  of  Bronchiectasis,  page  157. 
1^)3.   Mental  symptoms  of  depression,  or  true  psychosis,  together 
with  profound  physical  weakness,  are  common. 

The  treatment  depends  on  their  severity;  rest  being  sufficient 
in  the  less  severe  cases.  Sanitarium  treatment  is  necessary  in  the 
more  severe  cases. 

4.  The  possibility  of  meningitis  and  encephalitis  should  not  be 
forgotten. 

*  Method  of  L.  W.  McGuire  and  W.  R.  Redden. 


177] 


CHAPTER  VI. 
PULMONARY  TUBERCULOSIS. 

By  John  B.  Hawes,  2nd,  M.D. 

Synonyms. —  Consumption,  Phthisis,  Tuberculosis  of  the  lungs. 

Etiology.  The  tubercle  bacillus,  discovered  by  Robert  Koch 
in  1882.  Tuberculosis  is  not  inherited.  It  is  of  the  utmost  im- 
portance that  this  should  be  clearly  and  definitely  understood  by 
everyone.  It  should  be  likewise  borne  in  mind,  however,  that  a 
predisposition  toward  the  disease  or  a  weakened  resistance  against 
it  may  be  and  often  is  inherited.  Among  the  factors  predisposing 
a  patient  toward  tuberculosis  are  overwork  or  bad  conditions  of 
work,  such  as  the  dangerous  trades,  etc.  A  trade  may  be  danger- 
ous because  of  its  inherent  qualities,  such  as  the  granite  and  iron 
industries,  which  are  dangerous  on  account  of  the  dust;  jewelry 
industries,  whereby  the  worker  is  exposed  to  acid  fumes,  etc.,  and 
many  other  such  occupations,  or  an  occupation  may  be  dangerous 
because  of  the  bad  conditions  under  which  the  work  is  carried  on. 
Among  such  bad  conditions  may  be  mentioned  poor  ventilation, 
exposure  to  extreme  heat  or  cold,  absence  of  sunlight,  etc.  Pov- 
erty and  poor  living  conditions  are  perhaps  the  most  important 
etiological  factors  in  tuberculosis.  The  whole  housing  problem  is 
intimately  mixed  up  with  that  of  tuberculosis.  Bad  habits, 
alcoholism,  etc.  are  factors.  Certain  acute  diseases,  such  as 
measles  and  whooping  cough,  may  leave  the  lungs  in  a  condition  to 
contract  tuberculosis  or  bring  into  activity  an  old  process.  The 
recent  epidemic  of  influenza  has  undoubtedly  brought  into  activity 
numerous  heretofore  quiescent  cases  of  tuberculosis,  while  in 
certain  cases  during  the  late  war,  exposure  to  poisonous  gases  has 
brought  about  the  same  result.  In  general,  anything  which  lowers 
the  bodily  resistance  is  a  predisposing  factor  toward  tuberculosis. 

COURSE  OF  THE  DISEASE. 

Pulmonary  tuberculosis  is  one  of  our  most  chronic  diseases.  It 
usually  lasts  from  two  to  seven  years.  In  certain  acute  cases, 
however,  where  the  patient  has  received  an  overwhelming  infec- 


[179  J 

tion  or  where  the  patient's  resistance  is  greatly  lowered,  it  may- 
run  a  more  rapid  course,  ending  fatally  within  a  few  months,  or 
even  weeks.  In  such  cases,  toward  the  end,  at  least,  the  disease 
is  not  confined  to  the  lungs,  but  becomes  a  general  septicemia, 
or  it  may  develop  into  a  tuberculous  meningitis.  Likewise,  al- 
thoi:gh  two  to  seven  years  is  the  average  course,  a  person  may  have 
tuberculosis  for  a  very  much  longer  time,  and  with  it,  live  to  a 
great  age.  In  fact,  it  is  undoubtedly  true  that  many  cases  of 
chronic  bronchitis,  winter  cough,  etc.  are  really  cases  of  this 
chronic  form  of  tuberculosis.  The  disease  is  characterized  by 
intermissions, —  periods  varying  from  a  few  months  to  many  years, 
during  which  it  is  inactive,  with  few  or  no  symptoms,  perhaps 
only  a  slight  morning  cough  and  raising  of  sputum.  During  this 
time  it  is  spoken  of  as  being  arrested,  or  semi-arrested,  or  even 
apparently  cured.  The  physician  is  rash,  however,  who  speaks  of 
any  case  of  pulmonary  tuberculosis  as  being  actually  cured.  The 
object  of  treatment  is  to  bring  about  as  permanent  arrest  as  possi- 
ble. 

COMPLICATIONS  AND  SEQUELAE. 

1 .  Tuberculosis  elsewhere  in  the  body,  especially  the  intestines, 
genito-urinary  tract,  and  fistula  in  ano. 

2.  Hemorrhage.  It  should  be  borne  in  mind  that  hemorrhage, 
though  always  an  alarming  symptom,  is  rarely  a  serious  one,  except 
when  the  disease  is  in  the  active  and  progressive  stage. 

3.  Cardiac  weakness,  due  to  the  toxins  generated  by  the  tubercle 
bacillus. 

DIAGNOSIS. 

In  the  diagnosis  of  any  case  of  tuberculosis,  bear  in  mind  the 
following: 

1 .  Absence  of  proof  is  not  proof  of  absence.  Because  you  can- 
not find  definite  proof  that  tuberculous  disease  is  present,  do  not 
assure  a  patient  that  he  is  not  tuberculous. 

2.  Differentiate  between  tuberculous  infection  and  tuberculous 
disease.  Practically  every  one  of  us,  by  the  time  the  fourteenth 
year  is  passed,  has  a  tuberculous  infection,  while  only  compara- 
tively few  of  us  are  doomed  to  have  tuberculous  disease.    The 


[i8i] 

distinction  is  of  immense  importance,  and  is  one  that  is  frequently 
lost  sight  of. 

3.  Errors  in  diagnosis  are  more  often  due  to  a  lack  of  thorough- 
ness and  because  the  physician  is  in  a  hurry  than  to  any  great 
inherent  difficulty  in  the  diagnosis  itself. 

4.  If  you  are  in  doubt  about  the  diagnosis,  do  not  be  afraid  to 
explain  this  frankly  and  openly  to  the  patient,  and  if  necessary, 
to  send  him  to  some  one  else  for  a  decision.  Remember  that  the 
patient's  whole  future  depends  upon  the  correctness  of  your 
diagnosis. 

History.  A  carefully  taken  history  is  of  immense  importance  in 
diagnosis.  Do  not  be  in  a  hurry,  but  be  prepared  to  take  the  time 
to  sit  down  and  talk  this  quietly  over  with  the  patient,  and  if 
possible  with  some  member  of  the  patient's   family. 

Family  History.  Inquire  in  every  case  if  any  member  of  the 
patient's  family  has  had  or  has  died  of  tuberculosis.  Do  not 
draw  too  many  conclusions  from  this,  however,  either  one  way  or 
the  other.  Remember  that  it  is  the  intimacy  of  exposure  in  child- 
hood, rather  than  exposure  in  adult  life  that  is  of  importance. 

Past  History.  Inquire  into  the  diseases  of  childhood,  with 
special  reference  to  measles  and  whooping  cough,  and  ascertain 
whether  or  not  there  was  any  period  of  invalidism  or  cough  follow- 
ing such  disease.  Find  out  whether  the  patient  was  looked  upon 
as  strong  and  robust  during  youth,  or  delicate.  Find  out  if  the 
patient  was  susceptible  to  coughs  and  colds,  and  inquire  into  such 
indefinite  conditions  as  "  run  down,"  "  slow  fever,"  "  debility," 
"  anemia,"  etc.  Such  terms  are  often  used  to  cover  the  physi- 
cian's inability  to  make  a  proper  diagnosis. 

Present  Illness.  Inquire  when  a  patient  last  felt  perfectly  well, 
as  well  as  when  he  first  felt  sick.  Ascertain  definitely  what  was  the 
first  symptom  or  group  of  symptoms  of  which  he  complained.  Do 
not  be  surprised  if  in  many  cases  no  mention  of  a  cough  or  sputum 
is  made.  Remember  that  the  onset  of  tuberculosis  is  more  often 
characterized  by  general  constitutional  symptoms,  such  as  loss  of 
weight,  strength,  energy,  etc.,  than  by  symptoms  relating  to  the 
lungs.  In  inquiring  in  regard  to  loss  of  weight,  bear  in  mind  the 
following  definition :  "By  loss  of  weight  should  be  understood  an 
unexplainable  loss  of  at  least  five  percent  below  normal  limits  for 
that  particular  individual  within  four  months'  time."     Likewise,  in 


[i83] 

regard  to  loss  of  strength:  "  By  loss  of  strength  in  its  pathological 
sense,  is  meant  undue  fatigue  and  a  lack  of  staying  power  which 
are  unusual  for  that  individual  patient  and  which  cannot  be 
satisfactorily  explained."  Inquire  in  every  case  as  to  whether  the 
patient  has  ever  spat  up  any  blood  or  has  had  a  hemorrhage  of  the 
lungs.  Go  into  the  details  of  this,  and  remember  that  hemorrhage 
may  be  defined  as  follows:  "  Any  amount  of  expectorated  blood, 
with  or  without  sputum,  may  mean  that  tuberculosis  is  present 
and  requires  careful  and  thorough  investigation  as  to  its  source. 
Blood  streaks,  blood  spots,  etc.  may  or  may  not  mean  tuberculosis. 
On  the  other  hand,  a  hemorrhage  of  one  or  two  teaspoonsful  is 
presumptive  evidence  of  the  disease." 

Cough.  Inquire  as  to  cough,  but  bear  in  mind  that  there  is  no 
cough  characteristic  of  tuberculosis.  There  may  or  may  not  be 
a  frequent  hacking  cough;  likewise,  there  may  be  any  other  kind 
of  a  cough.  Sputum  may  or  may  not  be  present.  The  absence  of 
sputum  does  not  in  any  way  militate  against  the  patient's  having 
tuberculosis. 

PHYSICAL  EXAMINATION. 

Fever.  Take  careful  observations  of  fever  over  a  period  of  at 
least  four  days,  four  times  daily,  and  remember  the  following 
definition:  "  An  occasional  temperature  of  99  should  not  be  con- 
sidered '  fever,'  A  temperature  which  persistently  runs  over  99.4 
when  taken  at  least  four  times  a  day  for  a  period  of  one  week  (by 
mouth  five  minutes)  should  be  considered  of  significance  and  to 
constitute  '  fever.'  "  While  a  fever,  as  defined  above,  is  not 
absolute  proof  that  the  patient  is  suffering  from  tuberculosis,  it  is 
presumptive  evidence  that  the  patient  is  suffering  from  a  toxemia 
of  some  kind.  In  the  absence  of  other  causes  for  such  a  fever, 
tuberculosis  should  be  very  seriously  considered. 

Elevation  of  Pulse.  Where  the  average  normal  pulse  is  already 
known,  an  elevation  of  1 5  beats  per  minute  when  the  pulse  is  taken 
quietly  at  home,  during  various  periods  of  ^'he  day,  should  be 
considered  abnormal.  In  cases  where  the  average  pulse  is  not 
known,  an  average  pulse  of  85  or  over  in  men,  and  90  or  over  in 
women,  may  be  considered  to  be  abnormal.  A  combination  of  a 
subnormal  temperature  and  an  elevated  pulse  as  defined  here  is  of 
great   importance.    Hyperthyroidism   and   certain   cardiac   dis- 


[i85] 

orders  are  the  commonest  causes  of  a  rapid  pulse  aside  from 
tuberculosis.  A  persistently  rapid  pulse,  however,  combined 
with  fever,  as  defined  above,  in  the  absence  of  hyperthyroidism  is 
evidence  in  favor  of  tuberculosis. 

Anemia.    This  may  or  may  not  be  present. 

General  Appearance  of  the  Patient.  Put  down  definitely 
whether  or  not  the  patient  looks  sick,  but  bear  in  mind  that  ex- 
tensive tuberculous  disease  of  the  lungs  may  be,  and  often  is, 
present  when  the  patient  presents  an  appearance  of  robust  health. 

Tuberculosis  Elsewhere  in  the  Body.  Tuberculosis  elsewhere, 
except  in  the  throat  or  intestines,  does  not  necessarily  indicate 
that  the  lungs  are  involved,  but  in  every  case  means  that  they 
should  be  carefully  examined. 

Hoarseness.  Any  hoarseness  or  persistent  huskiness  requires 
investigation.  A  tuberculosis  lesion  in  the  throat  or  vocal  cords 
is  presumptive  evidence  that  there  is  or  has  been  disease  in  the 
lungs. 

Sputum.  The  presence  of  sputum  is  not  necessary  for  a  posi- 
tive diagnosis.  Absence  of  bacilli  in  the  sputum  after  one  or 
several  examinations  is  not  necessarily  proof  that  there  is  no 
tuberculosis  present.  The  diagnosis  must  be  made  in  the  major- 
ity of  cases  before  the  sputum  is  positive. 

When  constitutional  signs  and  symptoms  are  absent  or  nearly 
so,  and  when  in  the  patient's  present  or  past  history  there  is  noth- 
ing that  points  to  tuberculosis,  definite  signs  in  the  lungs  including 
persistent  rales  at  one  or  both  apices  should  be  demanded  before  a 
definite  diagnosis  is  made,  in  the  absence  of  a  positive  sputum. 
By  "  persistent  "  is  meant  that  the  rales  must  be  present  after 
cough  at  two  or  more  examinations,  the  patient  having  been  under 
observation  for  at  least  a  month. 

When  there  are  definite  constitutional  signs  and  symptoms, 
such  as  loss  of  energy  and  strength,  fever,  rapid  pulse,  etc.,  it  is 
not  necessary  to  have  very  marked  signs  in  the  lungs  in  order  to 
make  a  positive  diagnosis.  In  the  majority  of  instances,  however, 
careful  examination  will  reveal  some  pubnonary  abnormality,  but 
not  necessarily  rales.  Usually  a  process  at  the  apices  should  be 
considered  tuberculous,  and  a  process  at  the  base  to  be  non- 
tuberculous  until  the  contrary  is  proved,  unless  there  is  a  clear 
history  of  pleurisy  with  effusion.     One  should  consider  a  typical 


[i87] 

pleurisy  with  effusion  as  presumptive  evidence  of  tuberculosis; 
a  dry  pleurisy  or  a  thickening  of  the  pleura,  requires  careful 
questioning  and  investigations,  but  is  not  necessarily  evidence  of 
tuberculosis.  When  in  doubt,  keep  the  patient  under  observa- 
tion for  at  least  one  month  with  repeated  sputum  examinations 
before  a  definite  diagnosis  is  made  one  way  or  the  other.  Depend 
more  on  the  thermometer  and  common  sense  than  on  the  stetho- 
scope, and  remember  that  "  absence  of  proof  is  not  proof  of  ab- 
sence." 

X-Ray.  An  X-Ray  examination  is  a  valuable  adjunct  and  may 
give  important  additional  information.  A  definite  diagnosis, 
positive  or  negative,  however,  should  never  be  based  on  the  X- 
Ray  examination  alone.  The  final  diagnosis  rests  in  the  hands  of 
the  clinician  and  not  with  the  roentgenologist. 


PROPHYLAXIS. 

Remember  at  all  times  that  tuberculous  infection  takes  place  in 
childhood.  Likewise  remember  that  adult  infection  is  rare,  and 
that  the  average  healthy  man  or  woman  living  under  normal 
hygienic  conditions  need  not  fear  contracting  tuberculosis.  The 
prophylaxis  of  tuberculosis,  therefore,  is  largely  the  protection  of 
infants  and  children  from  sources  of  infection.     This  means: 

1.  Destroying  all  sputum  whether  or  not  tubercle  bacilli  have 
been  found  in  it.  See  that  the  patient  uses  a  sputum  cup,  flask, 
or  cloth,  or  paper  napkins  which  can  be  burned. 

2.  See  that  the  patient  is  trained  to  place  his  hand  or  handker- 
chief in  front  of  his  mouth  when  coughing  or  sneezing.  Bear  in 
mind,  likewise,  that  this  applies  not  only  to  the  patient  with 
tuberculosis  but  to  every  individual,  man,  woman  or  child. 

3.  Make  it  an  absolute  rule  not  to  allow  a  consumptive  to  live 
intimately  with  children.  If  the  patient  cannot,  or  will  not,  take 
proper  precautions  or  go  to  a  proper  institution  for  treatment, 
the  children  should  be  removed  from  such  a  source  of  infection. 
Even  in  cases  where  the  danger  of  infection  is  apparently  very 
slight,  every  tuberculous  patient  should  be  carefully  instructed  to 
avoid  close  and  intimate  contact  with  children. 

4.  Careful  cleansing  of  the  room  or  premises  in  which  a  con- 


[189] 

sumptive  has  lived.  Chemical  fumigation  is  now  rarely  used. 
Mechanical  cleanliness,  soap,  water,  scrubbing,  repainting  and 
repapering  is  the  best  means  of  treating  such  rooms  or  premises  in 
order  to  make  them  safe.  Remember  that  sunlight  will  kill 
germs  of  tuberculosis  in  a  comparatively  short  while,  and  that 
under  ordinary  circumstances  blankets,  mattresses,  etc.  that  have 
been  used  by  a  consumptive  may  be  rendered  safe  by  exposure  to 
sunlight  for  a  few  hours. 

5.  Observance  of  the  ordinar}'  rules  of  hygiene  and  right  living 
as  to  work,  sleep,  play,  food  and  drink,  is  the  best  way  for  the 
average  person  to  avoid  contracting  tuberculosis. 


TREATMENT  IN  GENERAL. 

Treatment  of  the  Individual.  Treatment  should  be  active  and 
aggressive.  It  should  begin  as  soon  as  the  physician  has  made  the 
diagnosis  in  his  own  mind.  In  certain  cases  this  may  be  before 
he  has  seen  fit  to  tell  the  patient  definitely  that  he  has  consump- 
tion. In  the  vast  majority  of  cases,  however,  it  is  far  better, 
except  in  the  case  of  children,  to  talk  the  matter  over  plainly  and 
frankly  with  the  patient,  and  in  every  instance  the  physician 
should  make  the  exact  situation  clearly  understood  to  some  rela- 
tive or  friend.  Plain  medical  terms  should  be  used  as  much  as 
possible.  Do  not  tell  the  patient  that  he  has  weak  lungs,  a  spot 
on  the  lungs,  or  that  his  lungs  are  affected.  Let  him  know 
plainly  that  he  has  pulmonary  tuberculosis,  and  explain  exactly 
what  this  is,  and  what  it  means.  In  many  cases  it  is  wiser  not  to 
use  the  word  "  phthisis  "  or  "  consumption,"  as  both  of  these 
terms  are  apt  to  alarm  the  patient  and  his  friends  unnecessarily. 
If  you  yourself  are  in  doubt  about  the  diagnosis,  and  merely  sus- 
pect that  tuberculosis  is  the  cause  of  the  symptoms  but  are  not 
sure  of  it,  explain  this  situation  clearly  and  frankly  to  the  patient 
and  to  his  relatives  and  friends.  In  such  instances,  it  is  a  good 
rule  to  put  the  patient  on  trial  for  one  month,  and  to  let  him  know- 
that  if  at  the  end  of  this  time  he  is  not  distinctly  better  and  the 
symptoms  still  persist,  that  more  radical  treatment  will  have  to  be 
instituted.  In  certain  cases,  however,  owing  to  a  lack  of  intelli- 
gence on  the  patient's  part,  or  owing  to  improper  home  conditions, 


[191  J 

it  is  wiser  to  institute  sanatorium  treatment  at  once,  even  if  the 
diagnosis  is  not  clear.  Methods  of  treatment  include  the  follow- 
ing: 

1.  Sanatorium  treatment. 

2.  Home  treatment. 

3.  Climatic  treatment. 

4.  Tuberculin. 

5.  Heliotherapy,  or  sunlight  treatment. 

6.  Drugs. 

SANATORroM  TREATMENT. 

Despite  statements  to  the  contrary,  that  home  treatment  is  the 
best  method,  it  is  the  general  consensus  of  opinion,  demonstrated 
clearly  for  the  past  quarter  century,  that  sanatorium  treatment,  in 
the  broadest  sense  of  the  term,  is  the  best  method  that  is  at 
present  available  for  handling  the  individual  consumptive.  The 
patient's  length  of  stay  in  a  sanatorium  may  be  short  or  long, 
according  to  circumstances.  The  patient's  standard  of  intelli- 
gence, home  conditions,  finances,  mental  attitude  toward  treat- 
ment, are  all  factors  in  determining  the  length  of  stay  in  an 
institution,  but  it  may  be  safely  stated  that  at  some  time  or 
other,  the  vast  majority  of  tuberculous  patients  should  have  the 
training  and  instruction  that  only  a  sanatorium  can  afford.  It 
should  be  borne  in  mind,  however,  by  every  physician,  and  by 
him  imparted  to  his  patients,  that  sanatorium  treatment,  even 
of  long  duration,  rarely  if  ever  cures  a  tuberculous  process,  and 
that  the  best  it  can  do  is  to  bring  about  an  arrest  of  the  disease, 
which  may  continue  for  a  long  or  short  time,  as  the  case  may 
be.  The  patient's  stay  in  a  sanatorium,  important  and  vital  as 
it  is  to  his  welfare,  should  be  looked  upon  as  only  a  part  of  his 
treatment,  the  more  important  part  of  which  being  that  period 
which  follows  his  discharge  from  the  sanatorium.  Sanatorium 
treatment,  therefore,  in  its  broadest  sense,  should  mean  not  only 
that  the  patient  is  under  care  and  supervision  while  he  is  in  the 
institution,  but  that  the  details  which  he  has  learned  and  the 
methods  of  treatment  which  he  has  found  to  be  essential  to  his 
welfare  while  in  the  institution,  should  continue  for  months  or 
even  years  after  he  has  left  its  doors. 

In  many  states  of  this  country,  where  there  is  only  one  public 


1 193  J 

sanatorium  for  the  entire  population,  providing  a  number  of  beds 
utterly  inadequate  for  the  needs  of  the  community,  sanatorium 
treatment  in  such  instances  may  necessarily  be  reserved  for  the 
lucky  fewwho,  either  because  their  physical  condition  warrants  it, 
or  because  their  finances  are  able  to  afford  it,  are  able  to  secure 
admittance.  In  such  cases,  proper  home  treatment  is  the  only 
other  resource.  In  Massachusetts  and  in  other  eastern  states, 
there  are  enough  bed  facilities  for  practically  every  consumptive 
seeking  admission,  and  in  Massachusetts,  at  least,  a  consumptive, 
no  matter  how  poor  his  circumstances,  and  no  matter  how  far 
advanced  his  disease,  can  readily  secure  adequate  sanatorium  or 
hospital  treatment.  It  is  the  duty  of  every  physician  who  at- 
tempts to  handle  this  disease  adequately,  to  make  himself  ac- 
quainted with  the  facilities  open  for  consumptives  in  his  commun- 
ity. He  should  be  prepared  to  give  the  patient  accurate  details 
as  to  what  steps  he  must  take  for  admission  to  a  state,  county,  or 
local  sanatorium  or  hospital,  and  he  should  not,  as  is  too  often  the 
case,  deal  only  in  vague  generalities,  leaving  the  practical  details 
to  the  patient  or  his  family,  whose  burden  is  usually  already 
sufficiently  great. 

In  selecting  a  sanatorium  for  his  patient,  the  physician  should 
consider  the  following  points: 

{a)    Cost  per  week. 

{b)   Accessibilit}\ 

{c)    Climate  and  altitude. 

{d)   Temperament  and  disposition  of  the  patient. 

{e)    Length  of  time  patient  expects  to  remain  at  the  sanatorium. 

Cost  per  week.  Many  patients  are  apt  to  be  utterly  stampeded, 
when  they  are  first  told  that  they  have  consumption,  into  spending 
at  once  the  hard-earned  savings  of  years.  They  are  apt  to  scorn 
a  state  institution,  and  to  demand  at  once  that  they  be  sent  to  a 
private  sanatorium,  utterly  regardless  of  its  high  cost.  The 
physician  should  carefully  inquire  into  the  patient's  financial 
circumstances.  He  should  remind  him  that  he  is  dealing  with  a 
chronic  disease,  which,  unlike  t}^phoid  or  pneumonia  is  apt  to  last 
many  months  or  even  years.  The  patient  should  be  prepared  to 
put  aside  all  pride,  and  to  look  at  the  matter  from  a  sound,  eco- 
nomic viewpoint.  There  are  many  patients  who  refuse  to  go  to  a 
state  or  local  institution  because  they  believe  that  by  so    doing. 


LI95J 

they  become  objects  of  charit>^  This,  in  Massachusetts  at  least, 
has  been  done  away  with,  and  the  worthy  and  needy  patient  who 
receives  free  treatment  in  a  sanatorium  is  no  more  an  object  of 
charity  than  are  all  other  citizens  of  the  Commonwealth  who  are 
given  police  and  fire  protection,  and  free  education  for  their 
children. 

Accessibility.  One  of  the  most  important  factors  in  the  treat- 
ment of  tuberculosis  is  to  keep  the  patient  happy  and  contented. 
In  selecting  a  sanatorium,  therefore,  it  is  important  to  consider 
its  distance  from  the  patient's  home,  and  to  consider  the  expense 
and  time  necessary  for  friends  and  relatives  to  visit  the  patient. 
In  many  instances,  it  is  advisable  to  send  the  patient  to  an  insti- 
tution which  is  perhaps  not  so  well  located  in  other  respects  as 
compared  with  a  more  distant  one,  but  which  is  in  easy  reach  by 
train  or  trolley  for  friends  and  relatives. 

Climate  and  Altitude.  No  definite  law  can  be  laid  down  to 
either  climate  or  altitude  as  to  its  effect  on  the  individual  patient. 
Although  there  is  absolutely  no  doubt  that  a  suitable  climate, 
high  and  dry,  is  an  important  factor  in  the  treatment  of  tuber- 
culosis, to  the  vast  majority  of  patients  such  a  climate  is  impossi- 
ble. It  should  also  be  remembered  that  a  patient  who  is  sent 
away,  and  who  gets  well  in  such  a  favorable  climate,  may  never  be 
a;ble  to  return  to  his  home,  or  to  stand  the  climate  in  the  locality 
in  which  he  expects  to  live  and  spend  the  rest  of  his  life.  In  New 
England,  therefore,  and  in  the  majority^  of  the  Eastern  states,  for 
all  save  the  wealthy  consumptives,  it  is  better  for  the  patient  to 
take  the  cure  in  the  climate  in  which  he  expects  or  hopes  to  live. 
Much  the  same  applies  to  altitude  as  to  climate.  In  the  Eastern 
states  there  is  not  enough  altitude  to  be  an  important  factor  in 
treatment,  while  Colorado  and  the  West  is  full  of  patients  who  can 
maintain  their  health  under  western  conditions,  but  who  are 
prisoners  as  far  as  returning  to  their  homes  in  the  East  is  con- 
cerned. These  are  the  important  factors  which  should  be  care- 
fully considered  by  the  physician. 

Temperament  and  Disposition  of  the  Patient.  Happiness  and 
contentment  are  more  important  than  fresh  air  and  altitude  to  the 
majority  of  patients.  Here  again,  individualization  is  necessary. 
In  some  instances,  it  is  distinctly  better  for  the  patient  to  be 
separated  from  home  influences  and  surroundings.     Such  patients 


[  197  J 

are  apt  to  take  their  treatment  more  seriously,  and  to  realize  that 
they  are  to  work  on  a  very  grave  and  important  task.  On  the 
other  hand,  there  are  patients  for  whom  it  is  essential  that  they 
be  in  constant  and  near  communication  with  friends  and  relatives. 
The  best  of  food,  care  and  attention,  and  the  most  beautiful  sur- 
roundings will  avail  but  little  in  such  cases,  unless  there  is  mental 
peace  and  contentment. 

Length  of  Time  Patient  Expects  to  Remain  at  the  Sanatorium. 
If  the  patient's  home  conditions  are  such  that  treatment  may  be 
carried  on  very  well  after  he  has  learned  what  to  do,  he  may  be 
advised  to  go  to  a  private  sanatorium  for  a  few  weeks  or  months 
at  a  cost  which  it  would  be  utterly  impossible  for  him  to  continue 
for  six  months  or  a  year.  If,  however,  the  physician  believes  that 
it  is  wiser  for  the  patient  to  spend  a  long  period  at  the  institution, 
this  and  the  cost  per  week  must  be  given  careful  consideration. 

HOME  TREATMENT. 

Patients  may  be  divided  into  three  groups  as  far  as  home  treat- 
ment is  concerned: 

1.  Suspicious  cases,  cases  under  observation,  and  those  in 
whom  the  diagnosis  is  not  absolutely  definite. 

2.  Arrested  and  apparently  arrested  cases,  whether  or  not 
discharged  from  a  sanatorium,  and  those  in  whom  the  disease  is 
inactive. 

3.  Patients  with  active  tuberculosis  who  should  go  to  a  sana- 
torium or  hospital  but  who  by  force  of  circumstances  must  be 
treated  at  home. 

1.  Suspicious  cases,  etc.  It  should  be  made  clear  to  all  pa- 
tients in  this  group  that  home  treatment  may  be  only  a  temporary 
measure,  and  that  more  active  treatment  in  a  sanatorium  may  be 
and  probably  will  be  necessary. 

2.  Arrested  and  apparently  arrested  cases,  etc.  This  group  is 
a  large  one,  comprising  all  those  patients  who  have  spent  some 
time  in  a  sanatorium.  Whether  or  not  subsequent  home  treat- 
ment will  be  successful  depends  largely  upon  how  well  the  patient 
has  learned  his  lesson  while  in  an  institution.  Close  medical  and 
nursing  supervision  is  essential  in  these  cases,  if  the  good  done 
at  the  sanatorium  is  to  be  made  permanent.      There  is  no  class 


[199  J 

of  patients  in  whom  hard  work  on  the  part  of  the  physician  and 
nurse  will  bring  about  better  returns.  Home  treatment  is  natur- 
ally the  best  for  the  majority  of  these  cases.  How  strict  this 
should  be  in  regard  to  outdoor  sleeping,  rest,  etc.,  depends  on  the 
individual  case.  Frequent  visits  to  the  home  by  the  nurse,  and 
monthly  examinations  at  the  dispensary  or  doctor's  office  should 
be  required.  The  amount  of  work  done,  and  the  choice  of  em- 
ployment, are  to  be  decided  by  the  physician. 

3.  Patients  who  should  go  to  a  sanatorium  but  who  either  can- 
not or  will  not  do  so.  In  Massachusetts  and  in  many  of  the 
eastern  states  this  group  should  be  a  small  one;  elsewhere,  because 
of  lack  of  beds,  it  is  bound  to  be  a  large  group. 

The  essentials  of  successful  home  treatment  are: 

1 .  Adequate  and  detailed  supervision  of  the  patient  by  physi- 
cian and  nurse. 

2.  Close  cooperation  between  patient  and  physician. 

3.  Provision  for  outdoor  sleeping. 

4.  Prolonged  rest. 

5.  Finances  sufficient  to  insure  proper  food  and  nursing. 
Home  treatment  maybe  substituted  for  sanatorium  treatment, — - 

{a)   When  there  are  no  children  in  the  family  who  might  be 

exposed  to  the  disease  in  the  open  form. 
{b)   When  the  intelligence  of  the  patient  or  the  patient's 
family  is  such  that  adequate  carrying  out  of  details 
is  possible. 
{c)    When    adequate   nursing   and   medical   supervision    is 

available  over  a  sufficiently  long  period  of  time. 
{d)   When  there  are  facilities  at  home  for  proper  outdoor 
treatment  under  favorable  hygienic  surroundings. 
It  should  be  explained  to  the  patient  that  it  may  become  neces- 
sary at  any  time  for  him  to  return  to  the  sanatorium  or  hospital 
on  signs  of  an  impending  breakdown. 

Common  sense,  optimism,  patience  and  tact,  are  essential 
factors  in  treatment. 

CLIMATIC  TREATMENT. 

Before  advising  a  patient  to  undertake  a  journey  of  any  con- 
siderable distance  in  order  to  obtain  the  advantages  of  any  special 
climate,  the  physician  should  consider  the  following  points: 


L20IJ 

I.  The  cost  of  transportation,  and  the  cost  of  board  after 
arrivaL  No  patient  should  be  sent  to  Colorado,  for  instance, 
unless  he  has  at  least  $500.  or  better  still  $1000.,  with  which  to 
pay  the  necessary  expenses. 

1.  Will  the  patient  be  happy  so  far  away  from  his  relatives  and 
friends  ? 

3.  Has  the  patient  funds  sufficient  to  maintain  him  comfortably 
for  at  least  one  year? 

4.  The  physician  should  see  that  the  patient  is  placed  immedi- 
ately under  high-grade  medical  advice  as  soon  as  he  arrives  at  his 
destination.  This  should  never  be  left  to  chance,  nor  should  it  be 
left  to  the  patient  to  select  his  own  physician. 

5.  In  case  the  patient  has  shown  a  tendency  to  pulmonary 
hemorrhages,  or  in  case  there  has  been  any  sign  of  cardiac  weak- 
ness, if  the  place  to  which  you  are  considering  sending  him  is  at  a 
considerable  altitude,  will  it  be  safe  for  the  patient  in  question  ? 

6.  If  the  patient  is  in  the  far  advanced  or  progressive  stages  of 
the  disease,  in  the  majority  of  instances  it  is  unwise  to  send  him 
far  away. 

7.  Remember  in  every  case  that  even  if  the  patient  gets  an 
apparent  arrest  of  his  disease  in  a  certain  favorable  climate,  that 
it  may  be  impossible  for  him  to  live  in  any  other  climate,  or  to 
return  home  to  live  with  his  relatives  and  friends. 

On  the  other  hand,  the  physician  should  remember  that  it  is 
undoubtedly  true  that  there  are  many  cases  where  the  points 
above  mentioned  do  not  apply;  where  the  patients  will  be  dis- 
tinctly benefited  by  seeking  the  advantages  .which  a  different 
climate  and  perhaps  a  greater  altitude  can  provide. 

TUBERCULIN  TREATMENT. 

As  a  rule  the  general  practitioner  should  not  undertake  the 
treatment  of  his  patients  with  tuberculin.  This  should  be  left 
to  the  discretion  of  the  physician  who  has  had  experience  and 
training  in  this  method  of  treatment.  While  it  has  been  fairly 
definitely  proven  that  in  certain  selective  cases  treatment  with 
tuberculin,  carefully  carried  out  for  a  long  period  of  time,  seems  to 
prevent  a  certain  percentage  of  relapses  that  would  otherwise  have 
occurred,  if  carelessly  handled  by  those  inexperienced  in  its  use 
tuberculin  can  do  distinct  harm. 


[  203  ] 

HELIOTHERAPY  OR  SUNLIGHT  TREATMENT. 

Under  careful  supervision  this  may  be  applied  in  certain  cases 
of  pulmonary  tuberculosis.  A  physician  should  not  use  this 
method  of  treatment,  however,  until  he  has  made  a  careful  study 
of  the  subject  and  familiarized  himself  with  all  its  details.  It  is 
of  particular  value  in  the  case  of  children  with  tuberculosis  of  the 
bronchial  glands  or  elsewhere.  It  should  be  borne  in  mind,  how- 
ever, that  sunlight  is  a  powerful  agent  and  may  do  harm  as  well  as 
good.  The  general  principle  of  sunlight  treatment  is  to  expose  the 
body  gradually,  one  part  at  a  time,  to  increasing  amounts  of  sun- 
light so  that  eventually  the  skin  of  the  entire  body  becomes  deeply 
pigminted.  It  is  a  curious,  but  well  known,  fact  that  those 
patients  whose  skin  shows  a  tendency  to  burn  rather  than  to  tan 
do  not  react  well  to  sunlight  treatment.  In  the  treatment  of  all 
cases  the  head  should  be  kept  covered,  and  there  should  be  a  wet 
cloth  over  the  cardiac  area  when  the  chest  is  being  exposed. 

Sunlight  treatment  is  of  particular  value  in  the  high  altitudes 
where  there  is  not  only  apt  to  be  more  sunlight,  but  where  the 
rarified  condition  of  the  air  allows  a  larger  proportion  of  the  sun's 
rays  to  penetrate.  To  many  patients  in  the  East,  sunlight  treat- 
ment is  hardly  available. 

TREATMENT  BY  DRUGS. 

Drugs,  in  the  treatment  of  pulmonary  tuberculosis,  are  used 
merely  to  treat  symptoms,  never  the  disease  itself.  The  intestinal 
tract  must  be  kept  clear,  hence,  saline  or  vegetable  laxatives  are 
often  needed.  Diarrhea  must  be  checked.  Excessive,  unpro- 
ductive and  irritating  cough  must  occasionally  be  allayed.  In 
certain  instances,  a  mild  tonic  to  stimulate  appetite  is  indicated. 
Aside  from  these,  no  drugs  are  needed  in  the  treatment  of  pul- 
monary tuberculosis. 

TUBERCULOSIS  IN  CHILDREN. 

DIAGNOSIS 

The  physician  should  bear  in  mind  always  that  the  younger  the 
child  the  more  nearly  does  tuberculous  infection  approach  to 
tuberculous  disease.     A  positive  tuberculin  test,  whether  sub- 


[  205  ] 

cutaneous,  cutaneous,  or  intracutaneous,  in  a  child  five  years  or 
under,  carefully  performed  and  found  positive  after  one  or  more 
applications,  in  the  majority  of  cases  means  tuberculous  disease 
as  well  as  tuberculous  infection.  Remember  at  all  times  that  in 
childhood  the  infection  takes  place  first  in  the  glandular  system, 
and  that  by  the  time  the  lungs  are  definitely  involved  the  disease 
is  in  the  advanced  stages.  It  is  here  that  the  X-ray  will  give 
specially  important  and  valuable  evidence,  but  as  in  the  case  of 
adults  X-ray  evidence  alone  is  not  sufficient  on  which  to  base  a 
diagnosis.  If,  however.  X-ray  examination  shows  evidence  of 
enlarged  bronchial  glands  and  the  child  shows  constitutional  signs 
and  symptoms,  fever,  loss  of  weight  and  strength,  etc.,  a  positive 
diagnosis  should  be  made  even  if  according  to  clinical  examination 
localizing  signs  in  the  lungs  are  conspicuous  by  their  absence. 

TREATMENT. 

There  is  no  more  favorable  method  of  preventing  tuberculosis 
among  adults  than  by  the  early  and  active  treatment  of  tuber- 
culous infection  among  children.  For  those  children  who  show 
signs  of  active  disease  as  described  above,  the  tuberculosis  hospital, 
sanatorium  or  the  so-called  "  preventorium  "  is  the  best  and  most 
efficient  means  of  treatment. 

The  source  of  infection  in  every  case  should  be  diligently  sought 
for  and  eradicated  if  possible,  whether  this  be  bovine  or  human. 

For  those  children  in  whom  the  evidence  of  disease  is  not 
sufficient  grounds  for  breaking  up  the  home  or  sending  them  away, 
the  out-door  school,  the  fresh  air  room,  and  the  advice  and  super- 
vision of  the  tuberculosis  nurse,  and  adequate  medical  care,  are 
the  best  means  available  for  building  up  the  child's  strength  so 
that  the  tuberculous  infection  will  not  become  tuberculous  disease. 


NON-PULMONARY  TUBERCULOSIS. 

Although  not  properly  included  in  the  scope  of  this  chapter,  it 
is  not  out  of  place  to  call  attention  to  certain  points  concerning 
this  form  of  tuberculous  disease.  The  physician  should  bear  in 
mind  at  all  times  that  tuberculosis,  whether  it  occurs  in  the  lungs 
or  in  the  bones,  joints,  glands  or  other  organs,  is  due  to  the  same 


[207  J 

organism  no  matter  where  the  disease  is  located,  and  that  while  in 
many  instances  surgical  methods  are  needed  in  the  non-pulmonary 
form  of  the  disease,  in  every  case  sunlight,  fresh  air,  rest,  proper 
food  and  hygiene  are  indicated.  The  physician  treating  this  form 
of  tuberculous  disease  should  remember  at  all  times  that  it  is  not  a 
tuberculous  gland  or  joint  which  is  under  consideration,  but  a 
man,  woman  or  child  who  has  the  disease. 

It  is  in  this  form  of  tuberculosis  that  treatment  by  means  of 
tuberculin  and  heliotherapy  brings  about  the  most  striking  results. 


TREATMENT  OF  THE  TUBERCULOSIS  PROBLEM. 

Every  physician  has  a  duty  to  perform  not  only  toward  his 
individual  patients,  but  one  that  concerns  the  tuberculosis  prob- 
lem as  a  whole.  Community  health  although  less  tangible  than 
the  health  of  the  individual  is  nevertheless  of  essential  importance. 
Any  disease  which  kills  over  200,000  persons  in  this  country  every 
year  constitutes  a  menace,  in  the  elimination  of  which  the  medical 
profession  should  be  the  leaders.  As  far  as  tuberculosis  is  con- 
cerned the  general  practitioner  can  and  should  help  in  the  follow- 
ing ways : 

1 .  He  should  be  a  member  of  his  local  tuberculosis  organization, 
or  if  none  such  exists  should  be  active  in  forming  one. 

2.  He  should  join  his  state  association  and  the  National 
Tuberculosis  Association. 

3.  He  should  make  himself  thoroughly  familiar  with  the  local 
needs  of  his  community  and  should  help  to  establish,  (a)  a  tuber- 
culosis dispensary;  (b)  a  visiting  tuberculosis  nurse;  (c)  proper 
school  hygiene  and  inspection;  (d)  proper  industrial  and  factory 
hygiene  and  inspection. 

4.  He  should  find  out  what  facilities  his  state  already  provides 
for  consumptives,  vv^hat  it  does  to  prevent  the  spread  of  this  disease, 
and  what  further  facilities  and  provision  are  needed  for  the  future. 

5.  He  should  use  his  own  personal  influence  with  city  and  state 
legislation,  along  with  that  of  his  state  medical  society,  as  a  whole, 
to  bring  about  proper  health  legislation  to  handle  the  tuberculosis 
problem. 

6.  He  should  report  all  active  cases  of  pulmonary  tuberculosis, 


[209] 

especially  those  with  a  positive  sputum,  promptly  and  accurately, 
and  should  cooperate  with  and  not  oppose  the  efforts  of  local  and 
state  health  authorities. 

The  following  are  the  most  important  measures  and  provisions 
that  every  community,  state  or  municipal,  aims  to  establish.  It 
is  the  dutv"  of  the  medical  profession  to  help  in  this  work. 

{a)  Beds  in  hospitals  and  sanatoria  for  consumptives  in  pro- 
portion of  one  bed  for  every  death  from  this  disease. 

{F)  Sanatorium  provision  for  early  and  favorable  cases;  hospital 
provision  for  advanced,  progressive,  and  emergency  cases. 

{c)  A  tuberculosis  dispensary,  which  should  include  a  tuber- 
culosis nurse,  for  every  city  or  town  of  10,000  inhabitants  or  over. 

{d)  School  inspection  with  a  school  nurse,  and  open-air  schools 
and  fresh-air  rooms  for  children. 

{e)  A  proper  system  of  factory  inspection  with  a  nurse  to 
assist. 

if)  Adequate  ways  and  means  to  educate  the  medical  profes- 
sion in  the  early  diagnosis  of  tuberculosis,  and  the  general  public 
concerning  its  frequency,  methods  of  avoiding  contracting  tuber- 
culosis, and  especially  its  prevention. 


[211] 

CHAPTER  VII. 
GASTRO-INTESTINAL  DISORDERS. 
GASTRIC  AND  DUODENAL  ULCER. 

INDICATIONS  FOR  MEDICAL  TREATMENT. 

1.  Recent  ulcers. 

2.  Chronic  ulcers  with  mild  symptoms. 

3.  Chronic  ulcers  which  have  not  had  satisfactory  medical 
treatment. 

4.  Ulcers  for  which  surgical  treatment  is  too  dangerous  or  has 
been  refused. 

5.  As  a  preparation  for  operation. 

The  prognosis  under  medical  treatment  is  better  the  more 
recent  the  ulcer. 

PRINCIPLES  OF  TREATMENT. 

The  principles  and  methods  are  essentially  the  same  whether 
the  ulcer  is  in  the  stomach  or  in  the  duodenum. 

1.  Prolonged  rest  for  the  patient  and  for  the  digestive  tract. 

2.  Avoidance  of  food  mechanically  or  chemically  irritating. 

3.  Reduction  of  gastric  secretion  to  the  minimum. 

4.  Good  care  of  teeth. 

METHODS. 

A.   Rest  for  a  month  or  more  is  essential. 

J5.  Diet  should  consist  chiefly  of  soft  carbohydrates,  fats,  milk, 
and  eggs.     Feeding  should  be  frequent. 

Treatment  may  be  begun  by  starvation  for  several  days,  if 
the  stomach  be  very  irritable.  Nutritive  enemata  are  seldom, 
if  ever,  of  much  value  because  they  are  not  well  absorbed.  During 
the  period  of  starvation  three  pints  of  salt  solution  should  be  given 
daily  by  rectum.     Cracked  ice  may  be  sucked  to  allay  thirst. 

Begin  feeding  with  small  quantities  of  milk  (see  Vomiting, 
p.  223).  Later,  bread,  or  crackers  and  milk,  milk  toast,  strained 
cereals  with  cream  and  sugar,  rice,  custard,  blancmange,  junket, 
simple  ice  cream,  mashed  or  baked  potato  with  cream  or  butter. 


[213  J 

eggnog,  raw  or  soft  boiled  or  dropped  egg,  pursee,  soft  fruits,  etc., 
can  be  added  later  to  the  dietary  until  the  patient  is  taking  ample 
nourishment. 

The  nutritive  value  of  liquids  can  be  much  increased  by  add- 
ing to  them  sugar  of  milk,  fr.  |  to  i  oz.  in  4  oz.  (or  fr.  1 5  to  30  gm. 
in  120  mils.)  of  liquid.  Cream  may  be  added  to  milk,  and  butter 
should  be  used  freely. 

Irritating  foods,  e.g.,  coarse  vegetables,  condiments,  acids,  and 
particularly  alcohol  must  be  avoided. 

Hot  drinks  and  meat  broths,  as  a  rule,  should  not  be  taken. 

Proteid  foods,  in  the  opinion  of  the  writer,  are  to  be  avoided, 
as  a  rule,  except  in  the  form  of  milk  or  eggs. 

C.  Modification  of  diet  is  required  for  patients  that  are  ema- 
ciated, or  feeble  and  anemic.  For  them  starvation  may  be  harm- 
ful, and  it  may  be  wise  to  begin  feeding  by  mouth  soon  after  the 
hemorrhage  has  stopped,  and  quickly  to  increase  the  amount  of 
food  ingested  in  order  to  accelerate  healing  by  improved  nutrition. 
The  experience  of  the  patient  with  the  peculiarities  of  his  digestion 
requires  consideration. 

In  marked  contrast  to  those  expressed  above  are  the  views 
held  by  some  physicians  who  advocate  a  diet  consisting  chiefly  of 
proteid.  Their  aim  by  means  of  proteid  is  to  neutralize  the  acid 
secretion  as  fast  as  formed.  Frequent  feedings  are  recommended 
with  the  same  object. 

Lenhartz  is  one  of  these,  and  his  method  may  be  preferred  for 
some  cases.    His  diet  schedule  follows,  p.  219. 

D.  Reduction  of  gastric  secretion  *  may  be  favored  by  starva- 
tion, by  a  diet  low  in  proteid,  by  the  avoidance  of  salt  and  by  the 
administration  of  |  to  i  tablespoonful  of  olive  oil  several  times 
daily. 

E.  Medication: 

1.  Sodium  bicarbonate  f  should  be  prescribed  freely  for  relief 
of  pain  or  distress  in  the  dose  of  |  to  i  teaspoonful,  or  more  if 
required,  in  a  glass  of  water.     A  hot  water  bag  may  relieve. 

2.  After  feeding  has  been  begun  bismuth  subnitrate  should 
be  given  three  times  daily  in  teaspoonful  doses  before  meals  with 


*  Small  doses  of  atropine  are  recommended  by  some  physicians, 
t  Magnesium  oxide  is  preferred  by  some  physicians. 


[215 

the  hope  of  benefit  by  coating  the  ulcer  mechanically.  Bismuth 
is  not  constipating  in  this  dose.  It  is  important  that  the  drug 
should  be  pure.* 

3.  The  bowels  should  be  kept  free  by  enema  or  by  mild  cathar- 
tics. Milk  of  magnesia  acts  well  as  a  mild  cathartic  and  also  as  an 
antacid. 

D.   Convaleseence : 

1.  General  hygienic  measures  including  attention  to  the  bowels 
are  important. 

2.  Work  should  be  resumed  gradually  and  much  fatigue, 
psychical  more  than  physical,  should  be  avoided. 

3.  Rest,  lying  down,  for  from  |  to  i  hour  after  meals  is  of  great 
benefit. 

4.  Food  should  be  taken  in  the  middle  of  the  morning,  the 
middle  of  the  afternoon  and  at  bedtime  in  addition  to  regular 
meals. 

5.  The  more  strictly  the  diet  and  regimen  can  be  followed  the 
greater  the  chance  of  success  but  it  is  better  to  enlarge  the  dietary 
than  to  undernourish  the  patient  because  good  nutrition  favors 
healing  of  the  ulcer.  The  treatment  should  be  followed  as  strictly 
as  practicable  for  from  six  months  to  a  year. 


COMPLICATIONS:  TREATMENT. 

A.   Hemorrhages,  when  small,  require  no  special  treatment. 

When  a  severe  hemorrhage  occurs  the  patient  should  lie  as  still 
as  possible  and  morphine  should  be  given  subcutaneously  in 
dosage  sufficient  to  bring  the  patient  well  under  its  influence  and 
to  inhibit  peristalsis  (p.  271).  Further  medication  is  not  likely  to 
do  good. 

An  ice-bag  may  be  placed  over  the  stomach. 

Stimulation  of  the  circulation  by  salt  solution,  by  transfusion 
of  blood,  or  by  drugs  should  be  withheld  unless  demanded  by 
immediate  danger,  because  raising  the  blood-pressure  may  prolong 
the  hemorrhage. 

If  syncope  be  feared  after  hemorrhage  it  may  be  advisable  to 
raise  the  foot  of  the  bed. 


Squibb's  is  good  for  this  purpose. 


[217] 

Operation  is  seldom  indicated  during  hemorrhage  because 
most  hemorrhages  stop  spontaneously,  and  because  when  the 
patient  has  become  exsanguinated  operation  is  dangerous. 

Repeated  hemorrhage  is  an  indication  for  operation  after  the 
patient  has  recovered  sufficiently  from  the  resulting  anemia. 
Transfusion  may  be  advised  to  hasten  recovery  or  to  prepare  for 
subsequent  operation. 

B.  Perforation  may  be  acute  or  subacute.     It  may  lead  to 

general  peritonitis,  to  abscess,  or  to  adhesions  causing  persistent, 
severe  symptoms. 

The  acute  perforations  and  those  with  abscess  formation  should 
receive  prompt  surgical  treatment.  Early  diagnosis  is  very 
important. 

C.  Pyloric  obstruction,  when  severe,  requires  operation.  In- 
complete obstruction  with  gastric  dilatation  can  often  be  relieved 
temporarily  and  sometimes  for  long  periods  by  rest  in  bed,  lavage 
daily  before  breakfast,  and  a  soft  diet  with  limited  liquids.  Under 
such  treatment  the  dilated  stomach  may  contract  and  acute 
inflammation  at  the  pylorvis  may  subside. 

This  is  an  excellent  preparation  for  operation.  Operation 
should  be  urged  early  for  pyloric  obstruction  because  when 
symptoms  make  it  imperative  the  weakened  condition  of  the 
patient  adds  greatly  to  the  risk. 

D.  Persistent  severe  symptoms  which  do  not  yield  to  medical 
treatment  demand  that  operation  be  seriously  considered. 


[219 


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[  221  ] 

ACUTE  INDIGESTION 

Pathology :  Probably  irritation,  with  hyperemia,  and  possibly 
with  inflammation  of  the  mucous  membrane  of  the  stomach,  of 
the  intestines  or  of  both. 

Etiology:  i.  Ingestion  of  food  unwholesome  either  in  itself  or 
for  the  individual. 

1.  Excess  of  food. 

3.   Excess  of  alcohol  or  other  beverage. 

Diagnosis  of  indigestion  is  made  by  history  and  by  exclusion. 

Do  not  overlook  the  following  diseases  which  may  cause 
vomiting: 


I. 

Acute  infectious 

diseases 

8. 

Brain  tumor. 

including  malaria. 

9. 

Tabes  dorsalis. 

2. 

Nephritis. 

10. 

Angina  pectoris. 

3- 

Pregnancy. 

II. 

Chronic  gastric  or  intestinal 

4- 

Migraine. 

diseases. 

5- 

Lead  colic. 

12. 

Acute    surgical    conditions, 

6. 

Hysteria. 

e.g.,    appendicitis,    chole- 

7- 

Acute  drug  poisoning. 

cystitis,  renal  colic,  etc. 

PRINCIPLES  OF  TREATMENT 

1 .  Rest  and  warmth  for  patient. 

2.  Removal  of  cause  of  symptoms. 

3.  Rest  for  digestive  tract. 

4.  Symptomatic  treatment. 

METHODS. 

Methods  must  be  chosen  with  regard  to  the  cause,  severity 
and  nature  of  symptoms. 

1.  Rest  and  Warmth.  The  patient  should  lie  down  and  should 
be  warmly  covered  or  should  remain  in  bed.  Hot-water  bags 
may  be  useful  for  cold  extremities  or  for  abdominal  distress  or 
pain.  Rest  and  warmth  diminish  metabolic  waste  and  promote 
recuperation. 

2.  Removal  of  Cause.  If  the  distress  is  gastric,  and  if  the 
stomach  has  not  been  freely  emptied,  emesis  may  be  induced  by 
administering  quantities  of  warm  water  or  by  means  of  a  tea- 
spoonful  of  mustard-powder  mixed  in  a  cup  of  warm  water. 


[223] 

If  symptoms  come  from  the  intestine  the  bowel  should  be 
evacuated  unless  profuse  diarrhea  has  cleared  it  thoroughly,  A 
saline  cathartic,  or  calomel  followed  by  a  saline  cathartic,  may  be 
of  service  if  the  stomach  can  retain  it.  An  enema  may  be  given 
at  any  time  for  prompt  effect  or  if  cathartics  cannot  be  retained. 
Both  emesis  and  catharsis  are  necessary  for  some  severe  cases. 

3.  Rest  for  Digestive  Tract.  Well-nourished  patients  generally 
do  best  without  food  of  any  kind  for  from  12  to  24  hours.  Plain 
water  or  mineral  water  may  be  allowed  in  small  quantities  at  short 
intervals. 

When  beginning  to  feed  it  is  wise  to  use  liquids,  such  as  beef 
tea,  chicken  broth,  hot  milk  or  orange  juice,  a  few  ounces,  every 
two  hours.  The  nourishment  should  be  increased  in  amount  and 
in  kind  more  or  less  rapidly  according  to  the  physician's  estimate 
of  the  patient's  digestive  capacity.  Hunger  and  a  clean  tongue 
generally  indicate  that  considerable  quantities  of  food  can  be 
assimilated;  whereas  a  coated  tongue  and  disgust  for  food  mean 
the  reverse. 

6.    Symptomatic  Treatment. 

(a)    Nausea  generally  yields  to  rest  and  abstinence  from  food. 

Emesis  is  advisable  for  some  cases. 
(i^)  Vomiting  usually  stops  spontaneously  when  the  stom- 
ach has  been  emptied.  If  it  does  not  yield  to  rest 
and  abstinence  from  food  it  may  be  checked  some- 
times by  a  teaspoonful  of  shaved  ice  with  brandy,  by  a 
drop  of  Tr.  of  iodine  in  a  teaspoonful  of  water,  by  |  gr. 
(or  0.016  gm.)  of  cocaine  hydrochloride  dissolved  in  a 
teaspoonful  of  water,  by  |  gr.  (or  0.008  gm.)  of  mor- 
phine sulphate  absorbed  from  the  mouth,  by  other 
drugs,  or  by  gastric  lavage.  Food  should  be  v/ithheld 
entirely  for  from  about  3  to  12  hours  after  vomiting 
has  ceased.  Water  should  be  allowed  during  this 
period  in  ver}-  small  amounts  if  at  all.  Cracked  ice 
may  be  sucked  for  thirst. 
When  gastric  disturbance  lasts  over  a  period  of  days, 
salt  solution  must  be  administered  in  the  form  of  ene- 
mata,  by  rectal  seepage  or  by  hypodermoclysis.  Three 
pints  in  24  hours  is  enough.  These  measures  and 
rectal  feeding  are  ver\^  rarely  needed  in  acute  gasti'itis. 


[225  J 

Feeding  should  be  resumed  cautiously,  using  milk  diluted 
with  mineral-water,  lime-water,  or  carbonated  water; 
or  orange  juice,  or  broth  in  teaspoonfuls  every  half  hour. 
The  quantity  of  nourishment  should  be  increased  and 
the  intervals  between  feedings  lengthened  gradually. 

(c)  Diarrhea  should  not  be  checked  until  all  old  fecal  matter 

has  been  discharged.  If  the  diarrhea  persists  in  a 
mild  form  a  few  doses  of  about  1 5  grs.  (or  i  gm.)  of 
bismuth  subnitrate  may  suffice  to  stop  it.  When 
diarrhea  is  severe  opiates  are  often  required.  A  tea- 
spoonful  of  paregoric  may  be  prescribed  after  each 
loose  movement.  Morphine  may  be  required  sub- 
cutaneously.     For  other  medicaments  see  below. 

(d)  Colic  can  be  checked,  when  slight,  by  the  application  of 

heat  to  the.  abdomen  and  by  rest  and  abstinence  from 
food. 
Paregoric  or  other  preparations  of  opium  or  morphine 
may  be  used  for  severe  pain  but  they  are  contraindi- 
cated  in  full  dosage  until  the  intestinal  tract  has  been 
cleared,  and  also  when  conditions  which  may  require 
surgical  interference  cannot  be  ruled  out. 


SIMPLE  DIARRHEA. 

DIAGNOSIS. 

Do   not   overlook   the   following   diseases   which   may   cause 
diarrhea. 

1.  Dysentery,  bacillary  or  amebic. 

2.  Other  infectious  diseases,  e.g.,  typhoid. 

3.  Nephritis  with  colitis. 

4.  Carcinoma  of  lower  bowel. 

5.  Fecal  impaction  with  intermittent  diarrhea. 

6.  Rectal  diseases  with  tenesmus. 

7.  Mucous  colitis. 

8.  Reflex  or  nervous  diarrhea,  e.g.,  due  to  chill,  exophthalmic 

goitre,  or  perhaps  to  anxiety. 

9.  Habitual  excess  in  eating  and  insufficient  exercise. 
10.   Irritating  ingesta  or  imperfectly  digested  food. 


[227] 

PRINCIPLES  OF  TREATMENT. 

Suit  methods  to  severity,  duration  and  persistence  of  symptoms: 
{a)   Remove  irritant,  usually  imperfectly  digested  food. 
{b)    By  means  of  a  suitable  diet  avoid  further  irritation. 
{c)    Limit  peristalsis. 

{d)  When  there  is  toxemia,  dilution  and  elimination  of  toxins 
is  important. 

METHODS. 

A.  To  Remove  Irritant.  Unless  bowel  has  been  thoroughly 
evacuated  prescribe  a  purge  which  will  act  quickly  and  ascertain 
that  this  result  has  been  obtained  before  proceeding  to  other  kinds 
of  medication. 

A  saline,  or  castor  oil,  may  be  used.     If  these  are  vomited  an 
enema  may  do  good.     It  may  be  advisable  to  induce  emesis. 
Calomel  generally  acts  well  (p.  295). 

B.  The  Diet  should  be  non-irritating;  should  leave  little  resi- 
due; and,  preferably,  should  be  digested  high  up. 

Eggs,  broths  and  lean  meats  are  well  digested  as  a  rule. 
Starches  containing  little  cellulose  may  be  preferred  occasion- 
ally. 
Fats,  fruits  and  coarse  vegetables  in  general  are  to  be  avoided. 
Liquids  should  be  bland  and  not  cold. 

C.  To  limit  peristalsis,     (a)    Rest,  preferably  in  bed. 

(b)  Restriction  of  ingesta.  Meals  should  be  small  and  fre- 
quent. In  severe  conditions  of  short  duration  food  and  liquids 
may  be  forbidden  entirely  for  a  time.  The  length  of  time  de- 
pends on  the  state  of  nutrition  and  tolerance  of  the  patient. 

{c)  Warmth,  externally  and  internally,  i.e.^  a  warm  100m, 
avoidance  of  changes  of  temperature,  a  hot-water  bag  on  abdomen 
and  hot  drinks. 

MEDICATION. 

id)  Astringents.  Bismuth  subnitrate,  fr.  10  to  20  grs.  (or  0.65 
to  1.3  gm.)  every  2  to  8  hours. 

Acidum  tannicum  (U.  S.),  boiled  green  tea,  red  wine,  or  Tan- 
nalbin  f  may  be  tried. 

{b)    Sedatives.     Opiates   are   best,   e.g.   Tr.   opii   camphorata 


[  229  ] 

(U.  S.)  "  Paregoric,"  or  Tr.  opii  deodorati  (U.  S.),  or  Misturae 
contra  diarrhoeam  (N.  F.  3d  ed.)  as  "  Cholera  mixture,"  "  Squibb's 
Diarrhoea  Mixture,"  and  others,  or  "  C.  O.  T.  pill  "  f  containing 
Camphor  i  gr.  (or  0.065  gi^-)>  Opium  |  gr.  (or  0.016  gm.),  and 
Tannic  acid  2  grs.  (or  0.13  gm.). 


CONSTIPATION. 

Constipation  is  a  symptom  seen  in  many  diseases,  some  func- 
tional, some  organic.  The  treatment  should  combat  the  cause  or 
causes  in  the  individual  case.  Hence,  a  clear  understanding  of 
every  case  is  of  prime  importance. 

CLASSIFICATION  OF  CONSTIPATION. 

I.  Spasmodic  Form:  90  per  cent  of  all  cases. 

(a)  Mucous  colitis. 

(b)  Neurasthenia. 

(c)  Lead  poisoning. 

(d)  Intra-abdominal  or  pelvic  inflammation. 

(e)  Fissure  of  anus. 

II.  Atonic  Form. 

Muscular  weakness  or  general  debility  due  to: 

1 .  Fevers. 

2.  Anemia. 

3.  Cachexia. 

4.  Senile  debility. 

III.  Obstructive  Form. 
(a)    Stricture. 

{i>)    Adhesions. 

(c)  Pressure  from  tumor  or  pregnancy. 

(d)  Ptosis  with  kink. 

(e)  Acute  obstruction. 

IV.  Less  common  varieties  of  constipation  are  excluded  from 
lack  of  space. 

Diagnosis  of  stricture,  adhesions  and  ptosis  or  kink  can  seldom 
be  made  satisfactorily  without  bismuth  x-rays,  but  x-ray  evidence 
is  often  misleading. 

t  Not  official. 


[231] 

PRINCIPLES  OF  TREATMENT. 

A.  The  essential  causes  of  chronic  constipation  are  bad  hygiene^ 
neurasthenia^  or  a  combination  of  both.  Therefore  it  is  often  im- 
perative to  encourage  the  patient  as  well  as  to  correct  his  habits. 

B.  Clear  the  intestinal  tract  thoroughly  and  keep  it  clear,  in- 
cluding the  rectum  cecum. 

C.  Soothe  or  stimulate  the  bowel  by  suitable  diet  as  required. 

E.  Use  cathartics  sparingly  or  not  at  all,  and  avoid  undue 
irritation  of  the  bowel  by  them. 

F .  Prescribe  sufficient  liquid  in  definite  quantity. 

G.  Enjoin  proper  mastication  of  food  and  prescribe  false  teeth 
if  needed. 

H.  Instruct  patient  about  regularity  in  defecation. 
/.    Exercise  or  abdominal  massage,  unless  contraindicated,  may 
help  sedentary  persons. 

SPASMODIC  CONSTIPATION. 

Note. —  Spasm  of  the  colon,  particularly  marked  in  the  region 
of  the  hepatic  flexure,  is  very  commonly  shown  by  the  X-ray  in 
cases  of  constipation.  The  cause  of  this  spasm  is  not  obvious  but 
personal  observation  has  led  me  to  believe  that  it  represents,  in 
many  cases,  a  response  to  irritation.  The  source  of  the  irritation 
may  perhaps  be  improperly  digested  food  or  retained  sciballae. 
Whatever  the  cause,  many  of  these  cases  show  abnormal  sensitive- 
ness to  deep  pressure  in  the  region  of  the  cecum,  the  sigmoid  or 
the  transverse  colon  and  many  are  operated  upon  for  "  chronic 
appendicitis."  The  relief  following  the  operation  is  generally 
transient  and  much  harm  may  result. 

Mucous  colitis  seems  to  be  a  more  advanced  stage  of  the  condi- 
tion outlined  above.  Neurasthenic  symptoms  are  prominent  in 
this  stage  but  are  often  in  evidence  much  earlier  if  not  from  the 
beginning. 

Proceeding  on  the  basis  of  the  theory  above  outlined,  the  follow- 
ing procedure  was  evolved  and  has  proved  its  value: 

Methods. 

(i)  Clear  the  bowel  thoroughly  using  oil  enemata  and  irriga- 
tions in  more  severe  cases  of  long  standing  and  castor  oil  or  calomel 
in  milder  cases. 


(2)  Restrict  diet  markedly  both  in  quantity  and  quality  for  the 
first  week  in  order  to  rest  the  bowel,  avoiding  anything  which 
might  act  as  an  irritant  to  it,  e.g.  foods  rich  in  cellulose,  acids, 
spices,  tea,  coffee  and  alcoholic  beverages. 

The  following  list  of  suitable  foods  is  not  complete,  and  should 
not  be  follovv^ed  too  closely  in  all  cases.  The  experience  of  the 
patient  may  be  valuable.  Fresh  milk,  cream,  butter,  sugar,  rice, 
macaroni,  sago,  tapioca,  strained  oatmeal,  cream  of  wheat,  white 
bread  or  toast,  potato,  baked,  boiled  or  mashed,  junket,  custard, 
blanc-mange,  eggs,  boiled,  poached,  scrambled  or  shirred,  finely 
minced  chicken  or  lamb,  boiled  tongue,  or  tender  steak  if  it  can  be 
well  chewed. 

(3)  x'^.fter  the  first  week  and  until  abdominal  sensitiveness  has 
disappeared  the  non-irritating  diet  should  be  continued  in  quantity 
sufficient  to  maintain  weight  and  variety  should  be  secured  by 
adding  to  the  list  from  time  to  time. 

(4)  Action  of  the  bowels  during  this  period  may  require  the 
daily  use  of  an  enema  but  agar  or  Russian  oil  (p.  297)  should  be 
given  and  may  suffice.  Cathartics  which  act  by  virtue  of  their 
irritating  qualities  are  to  be  scrupulously  avoided. 

(5)  Gradual  return  to  a  normal  diet  rich  in  cellulose  and  fruit 
should  follow  the  disappearance  of  abdominal  sensitiveness. 

(6)  General  hygienic  measures  are  very  important. 
Exercises  designed  to  improve  posture  and  to  strengthen  the 

abdominal  muscles  may  be  required  and  massage  of  the  cecum 
and  colon  may  be  helpful. 

Lead  Poisoning  with  Constipation.  Antispasmodic  medication 
with  morphine  or  atropine  is  required. 

Intra-abdominal  or  Pelvic  Inflammation  or  Fissure  of  the  Anus 
may  cause  constipation  by  reflex  spasm.  Treatment  demands 
removal  of  the  cause  by  appropriate  means. 


METHODS  FOR  ATONIC  CONSTIPATION. 

Post-febrile  constipation,  being  transient,  may  be  treated  with 
mild  laxatives  for  convenience. 

Constipation  in  Anemia,  Cachexia,  or  Senile  Debility.     The 

patient's  convenience  should  be  considered,  especially  in  ambula- 
tory cases,  or  when  the  chance  of  ultimate  cure  is  small.     Nux 


[  ^-3S  ] 

vomica  may  be  of  service,  and  mild  laxatives,  glycerine  supposi- 
tories, or  enemata  may  be  advised  according  to  circumstances. 
Fecal  impaction  should  be  guarded  against  and  water  catharsis 
must  be  avoided.  Massage  may  do  good  and  mechanical  support 
may  aid  defecation  when  the  abdominal  wall  is  weak. 

A  diet,  rich  in  cellulose,  fruits,  and  sugar,  may  help  to  stimulate 
peristalsis.  Graham  bread,  oatmeal,  cracked  wheat,  green 
vegetables,  beets,  carrots,  turnips,  tomatoes,  raw  or  stewed  fruits 
and  jams  are  particularly  to  be  recommended  for  those  who  can 
digest  them. 

METHODS  OF  TREATMENT  FOR  OBSTRUCTIVE  CONSTIPATION. 

{a)  Stricture.  Operation  will  generally  be  required.  Pallia- 
tion by  means  of  "  Russian  Oil  "  by  mouth,  or  by  rectal  injec- 
tions of  oil  followed  by  cleansing  enemata  may  be  beneficial. 

{b)  Adhesions.  The  palliative  measures  just  mentioned  may 
suffice.  Exercise  or  massage  may  do  good.  Operation  may  be 
advisable. 

{c)    Pressure.     Palliate  or  operate  according  to  circumstances. 

{d)  Ptosis.  A  suitable  abdominal  supporter  may  relieve. 
Other  palliative  measures  and  exercise  or  massage  may  help. 
Operation  offers  little  hope  of  relief,  as  a  rule. 

{e)    Acute  Obstruction.     Prompt  operation  is  imperative. 


METHODS  USEFUL  IN  VARIOUS  KINDS  OF  CONSTIPATION. 

I.  Massage  daily  may  be  very  beneficial. 

"  Cannon-ball  Massage."  A  heavy  ball  is  necessary.  A  12,- 
or  i6-lb.  "  shot "  (made  for  athletics)  and  covered  with  leather 
or  strong  cloth  will  serve.  Once  or  twice  daily  the  patient,  lying 
on  his  back,  should  roll  the  shot  repeatedly  around  the  abdomen  * 
from  the  cecum  along  the  course  of  the  colon  for  1 5  minutes  before 
going  to  the  toilet. 

II.  Enemata.  {a)  In  long-continued  constipation  the  rectum 
may  never  empty  itself  completely  ("  dyschezia  ").  As  a  result 
the  reflex  to  defecation  may  be  lost.  This  reflex  can  sometimes 
be  regained  after  a  course  of  oil  injections  at  night,  followed  by 


*  The  abdominal  muscles  should  be  relaxed  while  the  ball  is  bein^  rolled. 


cleansing  enemata  in  the  morning.  Olive  or  linseed  oil  is  suitable. 
From  4  to  6  oz.  (or  120  to  180  mils.)  should  be  used  at  each  injec- 
tion and  the  oil  should  be  retained  through  the  night. 

{b)  Cleansing  enemata  of  warm  water  with  the  addition  of 
Sod.  bicarb,  or  of  salt  i  drach.  (4,0  gm.)  to  the  pint  (500  mils.) 
can  be  used  when  irritation  of  the  mucous  membrane  is  to  be 
avoided. 

{c)  Cold  water,  hot  water,  or  soap  suds  and  water  are  more 
potent  than  salt  solution  or  warm  water. 

{d)  Strong  enemata,  consisting  of  glycerine  fr.  i  drach.  to  i  oz. 
(4  to  30  mils.) ;  or  of  Sat.  sol.  of  Mag.  sulph.,  glycerine,  and  water 
aa  2  oz.  (or  60  mils.)  can  be  used  if  required. 

III.  Laxatives  should  be  used  only  in  conjunction  with  suitable 
diet,  abundant  liquid  (6  to  8  glasses  of  water  daily)  and  hygienic 
habits.     No  one  laxative  suits  all  persons. 

{a)  Fl.  Ext.  of  Cascara  sagrada  can  be  used  in  doses  of  10  or 
15  min.  (or  0.6  to  i  mils.),  after  meals,  or  in  a  single  dose  of  10 
min.  to  30  min.  (or  0.6  to  2  mils.)  at  bed-time.  When  regularity 
of  the  bowels  has  been  established  the  dose  of  Cascara  can  be 
diminished  drop  by  drop  until  medicine  is  no  longer  required. 

{b)  Prunes  and  Senna.  Instruct  patient  to  stew  3  dozen 
prunes  with  two  tablespoonfuls  of  Senna  leaves  (enclose  leaves 
in  a  cheese-cloth  bag),  and  to  eat  10  prunes  once  or  twice  daily. 
When  the  bowels  have  been  regular  for  a  time  the  amount  of 
Senna  can  be  reduced  until  prunes  only  are  taken.  Later,  the 
number  of  prunes  can  be  reduced. 

{c)  Russian  Oil  or  Agar-agar  (p.  299)  may  be  tried.  They  act 
mechanically  and  do  not  irritate  the  intestines. 


239] 


CHAPTER  VIII. 
DIABETES  MELLITUS. 

By  B.  Harrison  Ragle,  M.D. 

Recent  research  and  advance  in  the  treatment  of  diabetes  lead 
us  to  conclude  that  it  is  much  to  the  patient's  advantage  to  have 
his  urine  rendered  sugar-free  and  to  keep  it  sugar-free.  Nor  is 
this  quite  enough.  The  blood-sugar  and  blood-fat  levels  *  should 
be  established  because  with  this  additional  data  to  guide,  both 
physician  and  patient  are  less  likely  to  go  astray.  When,  there- 
fore, the  diabetic  person  presents  himself  we  have  in  mind  the 
following  several  principles  of  procedure: 

PRINCIPLES  OF  TREATMENT. 

A.  Render  the  patient's  urine  free  from  sugar. 

B.  Reduce  the  blood-sugar  and  blood-fat  to  the  normal,  if 
possible  and  practicable. 

C.  Establish  a  proper  diet  to  accord  with  need  or  up  to  toler- 
ance. 

D.  Give  the  patient  as  thorough  an  understanding  of  the 
dietary  as  advisable  and  teach  him  to  do  the  simple  qualitative 
test  on  his  own  urine. 

E.  Rearrange  the  habits  of  living  to  conform  with  the  diet. 

F .  See  that  all  functions  and  organs  are  kept  in  the  best  possi- 
ble condition. 

METHODS  OF  TREATMENT. 

A.  To  render  the  urine  sugar-free  it  is  desirable  to  have  the 
patient  under  close  supervision  in  order  intelligently  and  safely 
to  limit  his  diet  or  to  fast  him.  It  is  quite  essential  to  understand 
the  patient's  temperament  and  to  learn  the  probable  cause  and 
duration  of  the  disease.  The  outcome  of  previous  attempts  at 
treatment,  and  the  knowledge  of  the  condition  of  the  organs  often 


*  It  is  rather  doubtful  whether  figures  for  blood-fat  are  important.  During  the  past 
two  years  little  information  of  value  has  been  drawn  from  approximately  looo  estima- 
tions. On  the  other  hand,  blood-sugar  estimations  are  constantly  assuming  greater 
importance. 


1 241 J 

give  fairly  precise  information  as  to  the  possibilities  in  a  given 
individual.  Unless  there  is  need  for  haste,  a  more  or  less  gradual 
reduction  of  the  diet  is  preferable  to  the  fasting  treatment.  The 
following  procedure  is  safe,  even  in  the  most  severe  cases: 

1 .  Elimination  of  fat  from  the  diet  in  practically  every  case  will 
clear  up  an  existing  acidosis  o*-  make  such  a  development  less 
likely. 

2.  A  test  diet  may  be  worked  out  and  applied  to  every  patient, 
or  the  dietary  may  be  adjusted  with  discretion  to  the  patient  con- 
cerned. Ordinarily,  a  diet  consisting  of  one  gram  of  carbohydrate 
and  one  gram  of  protein  per  kilogram  of  body  weight,  continued 
for  a  day  or  two,  orients  us  definitely  as  regards  the  severity  of  the 
case  in  hand. 

B.  Usually  the  urine  becomes  sugar-free  on  the  above  diet  and 
simultaneously  the  blood-sugar  and  blood-fat  drop  to  normal.  In 
more  severe  cases  in  which  this  latter  does  not  occur  the  carbo- 
hydrate should  be  completely  eliminated  from  the  diet  for  a  day. 

C  When  the  blood  figures  have  reached  a  low  or  normal  level 
five  grams  of  carbohydrate,  five  of  protein,  and  five  of  fat  may  be 
added  daily  to  the  diet  until  the  protein  has  reached  a  gram,  or  a 
gram  and  one-half  per  kilogram  of  body  weight.  The  carbo- 
hydrate and  fat  should  be  further  increased  until  the  mainte- 
nance *  diet  is  reached,  the  tolerance  is  reached,  as  indicated  by  the 
appearance  of  sugar  in  the  urine,  or  when  the  blood-sugar  begins 
to  rise  above  normal. 

The  final  diet  should  establish  nitrogen  equilibrium  (practically 
determined  when  loss  of  weight  ceases)  and  should  be  so  balanced 
that  the  intakes  of  carbohydrate,  protein,  and  fat  are  approxi- 
mately the  same  for  each  meal.  By  such  careful  measures  the 
body  will  not  be  flooded  at  any  one  period  above  its  metabolic 
capacity. 

D.  During  this  period  of  dietary  adjustment  the  patient  should 
watch  his  charts  daily  and,  if  possible,  figure  out  for  himself  the 
calories  the  diet  contains.  Simultaneously,  he  should  be  taught 
the  value  of  testing  a  complete  twenty-four  hour  specimen  of  urine 
and  should  learn  to  use  Benedict's  Solution  as  well  as  the  gram- 
scales  with  which  he  will  from  time  to  time  or  at  stated  intervals 


*  A  "maintenance  diet"  is  one  just  sufficient  to  maintain  body-weight  at  the  desired 
level  taking  into  consideration  the  circumstances  and  occupation  of  the  patient. 


[  243  ] 

weigh  his  food  in  order  to  become  conversant  with  approximate 
weights. 

E.  When  the  diet  has  reached  a  level  which  will  give  him 
sufficient  food,  or  has  reached  that  level  at  which  it  is  advisable  to 
let  it  remain,  the  patient  should  be  made  to  see  the  reason  for 
particularly  strict  adherence.  Then,  before  discharging  him  from 
immediate  supervision,  he  must  be  taught  that  on  a  restricted  diet 
his  activities  must  be  limited  in  order  to  accord  with  the  diet. 
The  failure  on  our  part  to  make  him  realize  that  he  has  a  limited 
tolerance  for  activity,  or  the  failure  on  his  part  to  pursue  the  regi- 
men laid  out  for  him,  leads  him  all  too  often  into  immediate 
difficulty  (viz.  a  patient  whose  diet  yields  1500  calories  may  re- 
main at  his  business  six  hours  and  take  a  two  mile  walk  and  find 
that  he  has  lost  no  weight  and  that  his  general  muscular  tone  at 
the  end  of  a  month  is  quite  as  good  as  ever.  The  second  month 
he  may  unwittingly  lengthen  his  business  hours  and  increase  his 
exercise  only  to  find  at  the  end  of  a  month,  much  to  his  chagrin, 
that  he  has  lost  five  pounds).  Especially  in  the  thin  diabetic  it  is 
our  duty  to  guard  against  loss  of  weight  whenever  possible.  At 
the  same  time  we  must  realize  that  almost  all  of  the  most  successful 
patients  are  those  who  have  slowly  lost  weight  considerably  below 
a  recognized  fixed  standard,  jealously  keeping  during  this  period 
their  muscle  tone  by  exercise. 

There  is  an  occasional  person  in  whom  a  knowledge  of  his  daily 
progress  creates  such  mental  disturbance  that  it  is  advisable  to 
put  the  care  of  his  case  in  the  hands  of  a  discrete  relative  or  nurse. 

A  proper  attitude  or  a  proper  philosophical  acceptance  of  his 
limitations  is  often  quite  as  important  to  the  patient  as  establish- 
ing a  diet  along  the  most  scientific  lines. 

F.  During  the  glycosuric  period,  the  diabetic  organism  becomes 
much  less  resistant  to  the  pyogenic  and  other  infections,  and 
convalesces  slowly  after  injury.*  Therefore,  we  should  investi- 
gate the  respiratory,  circulatory,  and  gastro-intestinal  systems 
and  endeavor  to  correct  any  disorders  that  are  found.  Acute 
visual  disturbances  usually  clear  up  when  the  urine  becomes 
sugar-free,  but,  inasmuch  as  good  vision  becomes  a  more  valuable 
asset  in  a  person  whose  activities  and  diversions  are  limited, 


*  During  aglycosuric  periods  the  diabetic  with  no  other  organic  disturbance  is 
seemingly  peculiarly  free  from  ordinary  infections. 


U45J 

glasses  should  be  ordered  or  corrected  as  indicated.  The  teeth 
and  gums  should  always  be  examined  carefully  because  dental 
sepsis  has  all  too  often  been  a  serious  factor  in  retarding  the 
progress  of  a  patient. 

FASTING  TREATMENT. 

Contraindications  to  fasting: 

{a)    Existing  acidosis. 

{]))    Infection,  with  fever,  or  toxemia. 

[c)  An  organic  complication  \  in  an  untreated  diabetic  on  a 
full  diet  whose  output  of  sugar  is  large. 

The  fasting  procedure  is  applied  with  safety  only  in  the  hands 
of  the  expert.  It  is  likely  that  he  will  only  fast  the  mild,  uncom- 
plicated diabetic.  When  used  with  discretion  this  method  saves 
a  little  time.  It  is  rarely  wise  to  starve  a  diabetic  more  than  three 
days.  If  the  urine  is  not  sugar-free  at  the  end  of  this  time,  three 
days  on  a  diet  moderately  high  in  protein  and  low  in  fat  and 
carbohydrate  followed  by  a  two-day  fast  will  prove  sufficient  to 
render  the  urine  sugar-free. 

ACIDOSIS. 

i\s  has  been  stated  above,  mild  acidosis  practically  always 
disappears  when  fat  is  reduced  or  eliminated  from  the  diet.  If 
the  acidosis  is  severe  and  does  not  quickly  respond  to  this  treat- 
ment it  is  because  the  alkali  reserve  of  the  body  has  been  con- 
siderably diminished.  Therefore,  we  should  treat  as  for  impend- 
ing coma,  as  follows: 

{a)   Bed-warmth. 

{]?)  Enema  (repeated  if  necessary)  to  empty  and  cleanse  the 
colon. 

(<:)  Fluids :  Water,  hot  diabetic  broths,*  tea  and  weak  coffee 
(300  cubic  centimeters  every  hour  for  four  hours,  and  200  cubic 
centimeters  every  hour  thereafter). 

{d)  Nourishment:  Endeavor  to  get  the  patient  to  take  50  to 
100  grams  of  carbohydrate  in  the  fo'-m  of  orange  juice  or  hot  oat- 
meal gruel  (30  gram.s  of  oatmeal  to  500  cubic  centimeters  of  water). 


\  e.  g.  a  serious  cardiac,  or  renal  lesion,  a  recent  trauma,  surgical  or  otherwise. 
*  A  "diabetic  broth"  may  be  made  from  meat  or  clams  and  if  from  the  former  the  fat 
should  be  skimmed  off. 


If  coma  is  really  impending  and  the  patient  not  able  to  take 
nourishment,  or  so  nauseated  that  he  cannot  retain  it,  resort  at 
once  to  500  cubic  centimeters  of  warm,  freshly  prepared  normal 
salt  solution  intravenously.  Administer  also  hot  rectal  saline  or 
hot  clear  broth. 

{e)  Stimulants:  Little  success  has  attended  the  use  of  strych- 
nine or  caffein.  The  latter  may  be  administered,  however,  in  the 
form  of  black  coffee.  It  is  probably  advantageous  as  a  diuretic, 
and  surely  beneficial  in  so  far  as  it  increases  the  intake  of  fluid. 
In  practically  all  cases  of  impending  coma  the  cardiac  muscle  is 
much  weakened.  Therefore,  digitalis  should  always  be  admin- 
istered, preferably  intravenously  or  intramuscularly. 

(/)  It  is  desirable  to  avoid  the  use  of  alkalis.  A  properly 
treated  case  will  rarely  have  a  depleted  alkali  reserve,  but  there 
are  the  neglected  cases  in  which  temporary  use  of  alkali  is  indi- 
cated. Twenty-five  grams  of  sodium  bicarbonate  may  be  taken 
daily  until  the  blood-bicarbonate  becomes  normal  or  the  urine 
becomes  alkaline  or  unless  by  such  treatment  the  patient  becomes 
nauseated.  The  very  severe  diabetic  who  runs  along  month 
after  month  on  a  much  restricted  diet  usually  has  a  low  blood- 
bicarbonate.  Such  a  case  will  benefit  by  an  occasional  short 
course  of  alkali.  (Sodium  Bicarbonate  should  be  given  until 
the  urine  becomes  alkaline).  Once  extolled  in  impending  coma, 
the  value  of  alkali  is  now  questioned  in  this  condition. 

COMPLICATIONS  IN  DIABETES. 

1.  Infections. 

2.  Furuncles  and  Sepsis. 

3.  Gangrene. 

4.  Nephritis. 

5.  Pregnancy  in  Diabetes. 

I.  Acute  Infections  in  the  diabetic,  even  when  mild,  are  always 
serious  unless  handled  skilfully,  because  all  the  symptoms  met 
with  in  fulminating  diabetes  may  appear.  The  patient  should  be 
treated  as  is  required  for  the  acute  infection  but  with  the  diet  so 
regulated  that  no  acidosis  will  occur  and  with  as  little  glycosuria 
as  is  possible.     In  giving  instructions  to  a  diabetic  patient,  it  is 


[  249  ] 

often  wise  to  advise  him  that  in  the  event  of  an  acute  infection 
such  as  tonsillitis  the  fats  should  be  omitted  from  the  diet  and  the 
carbohydrates  halved  until  he  obtains  further  advice  from  his 
physician. 

1.  Furuncles  and  Sepsis.  To  avoid  these  complications  by 
permitting  no  glycosuria  or  hyperglycemia  is  much  simpler  than 
to  cure  them.  Bruises  and  abrasions  should  be  treated  with 
utmost  care.  Infections  are  less  likely  to  occur  when  the  urine  is 
sugar-free  and  the  blood-sugar  at  a  low  figure. 

3.  Gangrene.  Avoidance  of  this  difficulty  is  possible.  To  our 
elderly  patients  with  endarteritis  obliterans  should  be  empha- 
sized the  wisdom  of  careful  trimming  or  filing  of  the  toe  nails. 
Woolen  socks,  warm  foot  baths,  massage,  leg  and  foot  manipula- 
tion, and  short  walks  should  be  prescribed. 

4.  Nephritis  is  no  contraindication  to  the  usual  diabetic  pro- 
cedure in  the  dietary.  Careful  adjustment  of  the  diet  and  habits 
of  life  often  leads  to  definite  improvement  of  both  above  men- 
tioned conditions.  By  giving  a  limited  but  necessary  amount  of 
protein  and  by  restriction  of  the  intake  of  salt  and  liquid,  non- 
diabetic  edema  can  be  relieved  should  it  occur. 

5.  Pregnancy  in  Diabetes.  Pregnancy  in  a  real  diabetic  is 
always  serious  and  requires  the  utmost  skill  in  management. 
Cooperation  between  the  obstetrician  and  the  physician  taking 
care  of  the  diabetic  situation  is  necessary  at  all  times. 

ETIOLOGY  OF  DIABETES. 

1.  Infections  —  Toxemias. 

2.  Obesity. 

3.  Menopause 

4.  Arteriosclerosis. 

5.  Heredity. 

6.  Prolonged  Great  Excess  of  Sweets. 

7.  Mental  Worry  and  Anxiety. 

8.  Hyperthyroidism  —  Enteroptosis. 

I.  I  beheve  that  infection  is  the  principal  cause  of  most  cases  of 
diabetes.  For  example,  it  is  as  reasonable  to  expect  a  pancreatitis 
as  a  nephritis  following  a  septic  sore  throat.     Not  infrequently 


[^51] 

slight  glycosuria  is  noted  simultaneously  with  temporary  kidney 
irritation.  Both  may  clear  up  temporarily  but  many  repetitions 
of  infection  may  lead  eventually  to  chronic  nephritis  or  to  diabetes. 

2.  Just  as  an  obese  person  becomes  the  victim  of  cardiac  or  of 
kidney  disease  because  of  the  excessive  burden  of  fifty  or  seventy- 
five  extra  pounds,  he  may  find  himself  a  victim  of  diabetes.  No 
type  of  diabetic  responds  so  regularly  to  present  day  treatment  as 
as  the  fat  diabetic.  Automatically,  with  the  removal  of  the 
burden,  the  organism  recuperates  and  with  wise  adherence  to  the 
regimen  little  difficulty  is  encountered. 

3.  A  disturbance  in  any  function  may  occur  during  the  meno- 
pause. Such  parenchymatous  changes  as  we  see  in  the  kidney 
may  also  occur  in  the  organ  or  organs  that  have  to  do  with  the 
development  of  glycosuria.  The  onset  of  diabetes  during  this 
period  is  so  frequent  that  it  is  a  wise  precaution  to  have  medical 
supervision  at  this  time. 

4.  Just  as  ateriosclerosis  lowers  the  function  of  the  kidney,  so 
also  may  it  lower  the  function  of  the  organ  or  organs  that  have  to 
do  with  diabetes. 

5.  Erroneous  training  permitting  self  indulgence  particularly 
in  those  things  that  favor  glycosuria,  may  be  behind  the  heredi- 
tary factor. 

6.  Prolonged  indulgence  in  sweets  is  too  often  a  part  of  the 
diabetic's  history  to  be  ignored  completely  as  a  factor  in  etiology. 

7.  Most  authorities  lay  emphasis  on  the  part  played  by  mental 
worry  and  anxiet>\  Probably  it  is  often  a  factor  in  etiology,  but 
most  surely  it  is  a  large  factor  in  hastening  the  progress  of  the 
disease  once  established. 

8.  Sugar  is  known  to  occur  frequently  in  the  urine  of  patients 
with  exophthalmic  goiter  and  occasionally  in  that  of  enteropto- 
tics.  Neither  condition  has  been  proven  to  be  important  in  the 
etiology. 

DIABETES  IN  CHILDREN. 

The  prognosis,  though  unfavorable,  is  not  so  hopeless  as  it  was  a 
few  years  ago.  Leading  authorities  agree  that  the  best  results 
are  obtained  and  the  child's  life  prolonged  by  rigorous  adherence 
to  the  principles  of  keeping  the  urine  sugar-free. 


[^53] 

TRANSITORY  GLYCOSURIA. 

It  is  safest  and  wisest  to  consider  every  person  excreting  any 
amount  of  sugar  as  a  diabetic  until  proven  otherwise.  The  bur- 
den of  proof  rests  with  the  physician,  and  I  am  always  reluctant  to 
take  the  responsibility  of  making  the  diagnosis  of  temporary 
glycosuria.     Every  such  case  is  a  potential  diabetic. 

RENAL  DIABETES. 

So-called  renal  diabetes  exists,  but  is  rare.  A  great  responsi- 
bility rests  on  the  physician  who,  without  the  most  careful  study, 
classifies  any  individual  in  this  group. 

EXCEPTIONAL  DIABETES. 

There  is  an  irregular  type  of  diabetes,  the  time  of  onset  of 
which  can  usually  be  traced  to  middle  age.  The  disease  goes  on 
for  many  years  without  causing  serious  symptoms,  and  this  class 
of  individual  may  experience  no  handicap  that  he  considers  un- 
associated  with  oncoming  age  until  there  takes  place  a  fairly 
rapid  loss  of  weight  and  strength,  accompanied  by  moderate 
increase  of  thirst,  appetite  and  frequency  of  micturition.  An 
injury,  sepsis,  or  an  acute  infection  may  be  the  cause  of  this  fairly 
rapid  decline. 

It  is  not  unlikely  that  this  group  comprises  the  majority  of 
those  diabetics  who,  late  in  life,  suffer  from  carbuncles  and  gan- 
grene. The  latter  trouble  is  probably  the  result  of  a  marked 
arteriosclerosis  which  is  almost  invariably  present.  The  basis  of 
their  glycosuria  may  be  arteriosclerosis  of  some  of  the  vessels  of 
the  pancreas  analogous  to  the  changes  of  this  character  which 
occur  so  commonly  in  the  kidney  with  advancing  years. 

The  best  method  of  treating  these  patients  is  still  in  doubt; 
but  it  is  probably  wise  to  impose  only  moderate  restriction  of  diet. 

NOTES. 

No  satisfactory  classification  of  diabetic  conditions  has  yet 
been  produced. 

For  accurate  observation  and  careful  asjustment  of  a  regimen, 
early  institutional  treatment  for  the  patient  is  desirable  except  in 


[255  1 

those  cases  where  the  general  condition  and  temperament  of  the 
individual  calls  for  a  thoroughly  experienced  nurse  capable  of 
carrying  out  treatment  in  the  home,  or  when  the  wife  or  house- 
keeper can  carefully  observe  every  detail  and  eventually  take  over 
this  responsibility.  Not  infrequently  when  the  patient  must 
depend  upon  himself  his  condition  preys  upon  his  mind  to  such 
an  extent  as  to  seriously  interfere  with  his  equanimity. 

Accurate  quantitative  determination  of  the  degree  of  acidosis 
can  be  made  simple  by  means  of  the  Van  Slyke,  the  Frederica,  or 
the  Marriott  apparatus. 

It  is  important  in  diabetes  to  keep  the  skin  in  good  condition 
For  this  purpose  frequent  warm  baths  and  occasional  massage 
with  cocoa  butter  or  lanolin  cream  are  beneficial. 

Exercise  should  be  insisted  upon  for  diabetics  and  in  many  cases 
it  should  be  taken  immediately  after  meals.  The  kind  and  amount 
required  can  be  learned  by  watching  the  effects. 

The  patient  whose  activities  are  limited  and  who  has  much 
spare  time  will  benefit  by  finding  a  hobby  or  diversion  such  as 
wood  carving,  whittling  toys,  or  knitting. 

Alcohol  is  no  longer  used  either  as  a  food  or  as  a  therapeutic 
measure  for  acidosis  in  diabetes. 

Surgery  can  be  performed  on  diabetics  with  proper  precautions. 

Local  anesthesia  should  be  used  whenever  possible  to  the  ex- 
clusion of  all  other  anesthesia.  Anesthesia  by  ether  or  chloro- 
form is  contraindicated. 

Gas  and  oxygen  in  the  hands  of  a  skilled  anesthetist  is  satis- 
factory.    Spinal  anesthesia  may  be  used. 

Early  restriction  of  salt  in  all  cases  seems  advantageous. 

A  vegetable  day  or  half-day  weekly  is  beneficial  in  the  severe  or 
moderately  severe  cases  v/hen  the  blood-sugar  remains  near  the 
danger  mark. 

A  fatless  day  each  week  is  prescribed  for  patients  whose  blood- 
fat  tends  to  creep  above  the  normal. 

The  patient  should  dress  warmly. 

Saccharine  may  be  permitted  up  to  3  grains  daily  but  should 
ordinarily  be  discouraged. 


[257  J 

CHAPTER  IX. 
MEDICATION. 

FOREWORD. 

He  who  masters  the  use  of  a  few  good  drugs  will  succeed 
better  than  he  who  tries  many  at  random. 

Before  prescribing  a  drug,  let  the  indications  for  its  use  be 
clear. 

Prescribe  drugs  singly  when  expedient. 

Ascertain  whether  an  idiosyncrasy  to  the  drug  you  wish  to 
prescribe  is  known  to  the  patient. 

When  a  drug  has  been  given,  watch  for  its  good  or  for  its  toxic 
effect.  Increase  dose  until  the  one  or  the  other  is  apparent. 
If  neither  results,  change  either  the  preparation  or  the  drug. 

If  toxic  effects  occur,  omit  the  drug  for  a  time  and  resume  it 
later  in  smaller  dosage  or  try  a  substitute. 

EXPLANATION. 

The  purpose  of  the  list  which  follows  is  to  indicate  the  important 
drugs  and  the  preparation  of  each  believed  to  be  the  most  gene^'ally 
useful.  The  dosage  recommended  is  suitable  for  the  average 
adult  and  may  require  modification  for  the  individual. 

Much  useful  information  is  contained  in  the  "  United  States 
Dispensatory."  It  describes  the  drugs  of  the  principal  phar- 
macopoeias, the  preparations  of  the  "  National  Formulary,"  and 
many  unofficial  preparations.  "  New  and  Non-official  Remedies  " 
gives  information  about  many  proprietary  drugs.  The  writer's 
information  about  patents  and  trademarks  was  derived  from  this 
book.  It  is  published  yearly  by  the  American  Medical  Associa- 
tion. 

LIST  I. 
VERY  VALUABLE  DRUGS. 

Page 

I .   Arsphenamine 259 

1.   Mercury 265 

3.   Iodide  of  Potash 269 


[  ^59  ] 

Page 

4.  Diphtheria  antitoxin 271 

5.  Morphine 271 

6.  Digitalis 275 

7.  Nitroglycerin  and  nitrites 281 

8.  Theobromine 283 

9.  Magnesium  sulphate 283 

10.  Quinine 285 

1 1 .  Salicylates 287 

12.  Hexamethylanamine 280 


SYNOPSIS  OF  LIST  I. 

I.   ARSPHENAMINE.  * 

Action.  Kills  certain  pathogenic  organisms  in  the  living  body. 
It  may  irritate  the  kidneys  or  liver  but  seems  to  have  no  toxic 
effect  per  se  for  other  organs. 

Elimination.  Excretion  rapid,  chiefly  in  urine  and  feces. 
When  the  excretory  organs  act  normally,  most  of  the  drug  is 
eliminated  on  the  first  day  and  nearly  all  within  three  or  four 
days  after  an  intravenous  injection. 

Toxic  ejects,  i.  Signs  of  renal  irritation  or  diminution  of 
kidney  function. 

2.  Jaundice. 

3.  Erythemia. 

4.  Hyperemia  and  swelling  at  the  site  of  syphilitic  lesions; 
i.e.^  "  Herxheimer  reaction."  To  this  group  probably  belong 
many  of  the  dangerous  symptoms  arising  within  three  days  of 
the  injection.  Among  them  may  be  mentioned  headache,  vomit- 
ing, earache,  syncope,  convulsions  and  coma. 

5.  Fever  developing  gradually  after  a  day  or  two  may  result 
from  rapid  destruction  of  spirochaetae. 

Accidents  or  errors  which  may  cause  severe  symptoms  or 
death: 

I .  The  "  water-error,"  i.f.,  contamination  of  the  distilled  water 
(used  for  solution)  with  bacteria  living  or  dead;  or  with  chemical 
impurities  from  the  distilling  apparatus.     Symptoms  that  have 

*  Not  official 


[  ^^6i  ] 

been  attributed  to  water-error  are  rigor,  rapid  rise  in  temperature, 
gastro-enteric  disturbances,  etc.  It  seems  probable  that  some  of 
these  symptoms  are  more  often  due  to  other  causes,  e.g.^  over- 
dosage. 

2.  Impurity  of  NaCl  or  of  NaOH  used  in  the  solution. 

3.  Oxidation  of  the  i\rsphenamine  may  be  followed  by  signs  of 
arsenical  poisoning,  gastro-enteric  disturbance,  peripheral  neu- 
ritis, paraplegia,  etc, 

4.  Accidental  use  of  an  acid  instead  of  an  alkaline  solution. 
The  former  is  10  times  more  toxic  than  the  latter. 

5.  Errors  in  technic  of  injection  may  result  in  venous  throm- 
bosis and  pulmonary"  embolism. 

6.  Use  of  the  drug  in  unsuitable  cases. 

7.  Lack  of  preparation,  or  of  after-care  of  the  patient. 

8.  Excessive  dosage  for  the  individual  under  existing  circum- 
stances, or  too  early  repetition  of  dose. 

9.  Combined  effect  of  various  factors  above  mentioned. 

10.   Neurorecurrence  appears  after  weeks  or  months  and  is  a 
recurrence  of  syphilis,  not  a  direct  effect  of  arsphenamine. 

Indications.  Suitable  cases  of  syphilis,  relapsing  fever,  yaws, 
and  various  other  diseases.  Arsphenamine  is  not  dangerous  when 
used  wisely  and  with  the  best  technic. 

Contraindications  are  relative  rather  than  absolute.  The  use 
of  arsphenamine  is  particularly  dangerous  when  the  patient  has: 

1.  Aneurism,  coronary  sclerosis,  myocarditis,  evidence  of  an- 
gina pectoris,  or  other  severe  lesions  of  the  circulatory  system. 

2.  In  non-syphilitic  nephritis. 

3.  In  some  cases  of  disease  of  the  liver,  pancreas,  or  adrenal 
glands. 

4.  Profound  anemia,  or  pronounced  cachexia  not  due  to  syphilis. 

5.  Severe  pulmonary  lesions,  or  marked  physical  weakness 
from  any  cause. 

Caution  is  advisable  when  there  are: 

1.  Syphilitic  lesions  of  the  central  nervous  system,  or  when 
their  presence  is  indicated  by  changes  in  the  spinal  fluid  or  sug- 
gested by  slight  symptoms. 

2.  In  the  secondary  stage  of  syphilis. 

3.  When  the  patient  is  alcoholic. 

4.  Shortly  after  fatigue  or  exertion. 


[--63] 

5-  When  excess  of  any  kind,  work,  or  travel,  cannot  be  pre- 
vented for  a  time  after  the  injection. 

6.   In  old  age,  or  when  there  is  advanced  arteriosclerosis. 

Administration.  An  infusion  apparatus  consisting  of  a  glass 
receptacle  with  an  opening  at  the  bottom^  a  rubber  tube  provided 
with  a  glass  window  at  the  lower  end,  a  clamp  and  a  needle  will 
suffice.  At  the  Massachusetts  General  Hospital  salt  solution 
is  used  to  establish  the  flow.  When  nearly  all  the  salt  solution 
has  left  the  receptacle  the  arsphenamine  is  poured  in.  Salt 
solution  is  poured  in  again  to  clear  the  needle  before  it  is  with- 
drawn. Care  is  taken  to  prevent  the  entrance  of  air  into  the  vein. 
About  five  minutes  is  allowed  for  the  passage  of  the  arsphenamine 
into  the  vein,  and  the  rate  of  flow  is  regulated  by  the  height  of  the 
receptacle. 

This  operation  requires  strict  asepsis  at  every  step. 

Dose.  Ordinarily,  o.i  to  o.6  gm.  is  used  at  intervals  of  from  5 
to  10  days.  In  rare  instances  smaller  or  larger  doses  may  be  tried. 
The  present  tendency  is  toward  small  doses  frequently  repeated. 

Caution.  When  danger  is  to  be  feared  begin  treatment  with 
a  series  of  very  small  doses  at  long  intervals,  or  an  energetic 
course  of  Mercury.  The  combined  use  of  large  doses  of  arsphena- 
mine and  of  Mercury  at  the  same  time  is  believed  to  be  unsafe. 

Note. —  Alternate  courses  of  arsphenamine  and  of  Mercury  are 
to  be  recommended  for  syphilis. 

NEOARSPHENAMINE.  * 

Action.  Like  that  of  arsphenamine  but  less  powerful  in 
equal  dosage. 

Toxic  Effects.  Similar  to  those  of  arsphenamine  but  milder 
with  equal  dosage. 

Indications.  It  may  be  preferred  to  arsphenamine  because 
easier  to  prepare,  or  when  toxic  effects  are  feared. 

Contraindications.    As  for  arsphenamine. 

Administration.  Use  immediately,  because  contact  with  air 
causes  rapid  decomposition.  Do  not  mix  the  drug  until  every- 
thing is  prepared  and  the  needle  already  in  the  vein. 

Dose.  0.9  gm.  of  Neoarsphen amine  contains  nearly  the  same 
quantity  of  arsenic  as  0.6  gm.  Arsphenamine.  ' 

*Not  official 


[265] 

Preparation  of  Alkaline  Solution  of  Arsphenamine  for  Intravenous 

Use. 

Printed   instructions  for  preparing  the  solution  are  provided 

with  the  drug. 

Technic  of  Mr.  Godsoe  at  the  Massachusetts  General  Hospital. 

1.  Everything  used  for  preparing  the  solution  is  sterilized 
beforehand,  and  is  handled  under  strictly  aseptic  precautions. 

2.  The  drug  is  dissolved  in  the  mixing  bottle  with  120  mils,  of 
0.6  per  cent  salt  solution  instead  of  distilled  water.  Solution 
takes  place  without  the  aid  of  beads. 

3.  To  a  dose  of  0.6  gm.  of  arsphenamine  thus  dissolved  5  mils, 
of  normal  NaOH  solution  is  added  and  the  mixture  is  shaken 
until  perfectly  clear.  The  dispensing  bottle  is  rinsed  with  the  solu- 
tion; the  solution  is  filtered  back  into  the  dispensing  bottle,  and 
after  insertion  of  the  stopper,  the  neck  of  the  bottle  is  covered 
with  sterile  gauze,  which  is  held  in  place  by  a  pin.  The  drug  is 
then  ready  for  use. 

Arsphenamine  may  decompose  within  a  few  hours.  It  should 
be  kept  cool  until  needed,  and  should  then  be  warmed  only  a 
little. 

List  of  Articles  Required  for  Preparing  Solution. 

1.  Burette  graduated  to  mils.,  containing  normal  NaOH  solu- 
tion. 

2.  Flask  of  0.6%  NaCl  solution. 

3.  Glass  funnel  and  filter  paper. 

4.  One  graduated  and  one  plain  8-oz.  bottle  having  glass 
stoppers. 

5.  Basin  of  antiseptic  containing  also  the  arripule  of  x'\rsphena- 
mine,  a  file  and  a  pin. 

6.  Sterile  sheet  and  s'ponges. 

2.   HYDRARGYRUM.     (U.  S.) 
"  Mercury." 
Important  preparations. 

{a)   Hydrargyri    saHcylas    (U.  S.).  *     "Mercuric    saHcylate." 


*  A  mixture  of  mercury  20.0  Lanolin  (anhyd.)  30.0  chloretone  2.0  and  olive  oil  to 
100. o  is  now  being  used  at  the  Mass.  Gen.  Hospital. 


[267] 

{b)  Hydrargyri  chloridum  corrosivum  (U.  S.).  "  Corrosive 
sublimate,"  "  Bichloride  of  mercury." 

(c)    Unguentum  hydrargyri  f  (U.  S.).     "  Mercurial  ointment." 

{d)  Hydrargyri  iodidum  flavum  (U.  S.).  "  Protiodide  or 
yellow  iodide  of  Mercury." 

Action  of  the  above  preparations  is  essentially  the  same:  anti- 
syphilitic,  local  irritant,  and  antiseptic. 

Elimination.  Chiefly  by  intestines  and  kidneys;  also  in  saliva. 
Excretion  is  slow. 

Toxic  Effects:  Acute  Poisoning:  stomatitis,  salivation,  renal 
irritation,  diarrhea,  abdominal  pain  and  gastric  disturbance. 

Chronic  Poisoning:  cachexia,  anemia,  etc. 

Indications :  Syphilis.  The  choice  of  a  mercurial  preparation 
depends  on  the  stage  and  severity  of  the  disease,  the  condition  of 
the  patient,  and  the  circumstances  under  which  the  treatment  is 
to  be  carried  out.  Each  of  the  four  preparations  mentioned  above 
has  advantages  lacking  in  the  others. 

Contraindications.    Nephritis  unless  luetic,  cachexia,  anemia. 

Administration  and  Dose. 

{a)  Hydrargyri  salicylas:  nearly  insoluble;  single  dose  10  to 
15  min.  (or  0.6  to  i  mil.)  of  a  10  per  cent  emulsion  of  the  drug  in 
Petrolatum;  repeat  in  from  5  to  10  days.  Inject  into  the  gluteal 
muscle.     Use  a  platinum  needle  i|  in.  long. 

{b)  Hydrargyri  chloridum  corrosivum:  soluble;  single  dose 
7  to  15  min.  (or  0.5  to  i  mil.)  of  a  i  per  cent  solution  of  the  drug  in 
a  10  per  cent  watery  solution  of  Sodium  chloride;  repeat  in  i  or  2 
days.     Inject  into  the  gluteal  muscle.     Use  a  platinum  needle. 

{c)  Unguentum  hydrargyri:  administer  by  inunction.  Dose 
I  to  I  drach.  (or  2  to  4  gm.).  Efficiency  depends  much  on  thor- 
oughness of  application, 

{d)  Hydrargyri  iodidum  flavum;  administer  in  pills  by  mouth. 
Dose:  |  gr.  /.  i.  d.  (or  0.013  gm.)  and  upward,  increasing  gradually 
until  the  first  signs  of  intolerance  appear.  Then  reduce  dose  by 
half  and  continue. 

Caution.  When  mercurials  are  given,  the  mouth  must  be  kept 
scrupulously  clean  to  avoid  stomatitis.  Teeth  should  be  brushed 
and  throat  gargled  after  every  meal.     If  there  is  pyorrhea  alveo- 


t  Conts.  about  50%  of  Mercury  by  weight.     Ung.  Hydrarg.  Dil.  (U.S.),  "Blue  oint- 
ment," conts.  about  23%  '^^  Mercury. 


[269] 

laris,  the  g'j.ms  may  be  scrubbed  with  castile  soap  or  swabbed 
daily  with  a  i  per  cent  solution  of  Potassium  permanganate,  ap- 
plied with  cotton  stick;  also  rinse  or  spray  mouth  with  Hydrogen 
peroxide.  When  giving  the  Prol  iodide  of  Mercury  and  Sodium 
or  Potassium  iodide  also,  give  ihe  Protiodide  a.  c.  and  the  Potas- 
sium iodide  p.c.  to  prevent  formation  of  the  Biniode  of  Mercury, 
When  using  large  doses  of  any  mercurial,  the  bowels  should  be 
kept  clear,  and  the  food  should  be  readily  digestible,  nutritious  and 
ample  in  quantity. 

Note. —  The  reader  is  advised  not  to  use  Mercury  in  large  doses 
or  by  injection  unless  familiar  with  the  details  of  its  administra- 
tion, dosage  and  indications.  Gottheil  gives  an  excellent  account 
in  Forchheimer's  "  Therapeusis  of  Internal  Diseases." 

3.   POTASSII  lODIDUM.     (U.  S.) 
*•  Iodide  of  Potash." 

Properties.     White,  crystalline,  very  soluble  in  water. 

Action.  I.  Causes  disappearance  of  gummata;  but  a  lesion 
which  disappears  while  iodides  are  being  taken  is  not  necessarily 
syphihtic. 

1.  Increases  fluidity  of  mucus  in  respiratory  tract.* 
3.   Seems  to  increase  thyroid  activity. 

Elimination.     Rapid,  chiefly  in  urine  as  salts,  partly  in  saliva.* 
Toxic  Effects :    Acute :    acne,  erythema,  and  other  serious  skin 
lesions,  catarrh  of  respiratory  organs,  gastric  disturbances,  de- 
lirium, etc.     Chronic:   loss  of  weight,  nervousness,  anemia. 
Indications,     i.   Late  stages  of  syphilis. 

2.  Bronchitis  with  sticky  expectoration. 

3.  Empirically  in  arteriosclerosis,  asthma,  lead  poisoning, 
simple  goitre,  and  many  other  conditions. 

Contraindications.  Acute  renal  irritation,  acute  inflammation 
of  the  respiratory  tract,  and  "  hyperthyroidism."  It  may  be 
harmful  in  phthisis. 

Administration,  i.  For  syphilis,  10  to  20  grs.  (or  0.6  to  1.3 
gm.)  t.  i.  d.  p.  c.  in  milk.  For  syphilis  of  central  nervous  system, 
increase  dose  rapidly  until  benefit  or  iodism  results.    One  hundred 

*  Bastedo. 


[  271  ] 

grains  (or  6.^  gm.)  t.  i.  d.  is  large  enough  dosage.  The  sat.  sol. 
in  water  is  convenient:  i  min.  =  i  gr.  (or  i  mil.=  i  gm.). 

1.  As  expectorant  give  5  to  10  grs.  (or  0.3  to  0.6  gm.)  t.  i.  d. 
p.  c.  well  diluted. 

3.   For  empirical  action  use  small  doses. 

Substitutes.  For  syphilis,  other  preparations  of  Iodine, 
Mercury,  or  Arsphenanine. 

As  expectorant:  Ammonium  chloride. 

4.  SERUM  ANTIDIPHTHERICUM.     (U.  S.) 
Dipntheria  Antitoxia.  * 

Action.     Curative  in  diphtheria. 

Absorption.     It   is   absorbed   slowly   from    the   subcutaneous 

tissues,  the  process  lasting  for  several  days. 

Toxic  Effects.     Urticaria,  erythema,  joint-pains,  etc. 

Indications.  Clinical  diphtheria;  and  for  those  exposed  to 
diphtheria. 

Contraindications.  Never  absolute.  Dangerous  in  sufferers 
from  horse  asthma.  It  is  doubtful  whether  a  single  dose  of 
antitoxin  ever  produces  sensitization  in  humans  sufficient  to  cause 
anaphylactic  shock  on  administering  a  second  dose. 

Administration.  By  injection  into  the  loose  subcutaneous 
tissues  of  the  abdominal  wall  or  below  the  angle  of  the  scapula. 

Intravenous  injections  are  best  for  severe  cases. 

Dose.  The  dose  should  be  gauged  according  to  the  severity  of 
symptoms,  duration  of  illness,  and  extent  and  location  of  the 
membrane,  f  Large  doses  are  indicated  when  the  larynx,  trachea, 
or  nasopharynx  is  involved,  and  especially  in  cases  of  virulent 
diphtheria. 

Therapeutic  dose  for  adults,  5000  to  100,000  units.  For  im- 
munization, 1000  to  2000  units. 

5.    MORPHINE  SULPHAS.     (U.  S.) 
"Morphine"  or  "Morphia." 

Properties.  White,  crystalline,  soluble  in  about  sixteen  parts 
water;  less  soluble  in  alcohol. 


*  Manufactured  by  Departments  of  Health  and  by  pharmaceutical  firms.     It  can 
be  obtained  from  the  State  Board  of  Health  in  Massachusetts  free  of  charge. 
t  See  Diphtheria,  p.  133. 


1 273  J 

Action.  I.  Diminishes  sensibility  to  lasting  impressions  and 
stimuli.     (Sollmann.) 

2.  Relieves  pain. 

3.  Slows  respiration  and  heart-action.     (Bastedo.) 

4.  Diminishes  metabolism. 

5.  Diminishes  peristalsis;   therefore,  constipating. 

6.  In  acute  cardiac  dilatation  gives  relief. 

7.  In  colic  or  intestinal  spasm  it  may  act  as  a  cathartic. 
Elimination.     Chiefly  by  gastro-intestinal  tract.     Some  is  oxi- 
dized in  the  body. 

Toxic  Effects,     i.    Somnolence  or  stupor. 

2.  Respiration  ven,^  slow  and  may  become  shallow  and  ir- 
regular (Cushny). 

3.  Pupillary  contraction. 

4.  Flushing  or  cyanosis  of  face. 

5.  Retention  of  urine. 

6.  During  recover\'  from  drug  nausea  is  common. 

7.  Death  results  from  depression  of  respiratory  center. 
Indications.     xA.cute  conditions  with:  — 

1.  Severe  pain. 

2.  Discomfort  preventing  sleep. 

3.  Acute  cardiac  insufficiency. 

4.  Internal  hemorrhage  (gastric,  pulmonary,  intestinal). 

5.  Persistent  vomiting. 

Contraindications.*  i.  Danger  of  forming  habit.  In  chronic 
or  recurring  non-fatal  diseases,  and  in  conditions  which  can  be 
relieved  by  milder  means,  use  morphine  with  caution  if  at  all. 

2.  When  bronchial  secretion  is  profuse  and  viscid,  morphine 
may  prevent  necessary  expectoration:  see  pneumonia,  p.  143. 

It  acts  well  in  some  cases  of  pulmonary  edema,  see  hyperten- 
sion, p.  23  and  toxemic  edema,  p.  47. 

3.  Idiosyncrasy:    causes  excitement,  vomiting,  depression. 

4.  Relatively  small  doses  should  be  used  in  infancy  and>  for 
elderly  persons.  Morphine  is  seldom  required  and  must  be  used 
with  caution  if  at  all  when  the  respiration  is  much  depressed  by 
toxemia,  e.g.,  in  uremic  conditions  with  Cheyne-Stokes  respiration. 


*  Codman  believes  that  morphine  after  abdominal  operations  may  induce  gastric 
dilatation;  and  Bastedo  says  it  should  not  be  used  in  "acute  dilatation  ot  the  stomach 
or  bowels." 


[  275  ] 

Administration.  For  urgent  conditions  give  subcutaneously 
in  the  dose  of  |  to  |  gr.  (or  0.008  to  0.032  gm.),  with  or  without 
atropine  sulphate,  o-^  to  yto  g^-  (or  0.00032  to  0.00052  gm.).  Mor- 
phine is  generally  given  by  mouth  in  tablet,  in  watery  solution, 
or  in  a  mixture.  Morphine  can  be  absorbed  from  the  mouth  and 
will  then  act  more  quickly  than  if  swallowed.  Atropine  given 
with  morphine  tends  to  diminish  the  gastric  disturbance  which 
may  follow.  Atropine  produces  toxic  symptoms  if  repeated  often 
in  full  doses. 

Substitutes :  Opium  in  pill,  as  tincture,  or  in  suppository. 

1.  Pilulse  opii  (U.  S.  VIII):  conts.  opium  i  gr.  (or  0.065  E^-) 
equal  to  morphine  |  gr.  (or  0.008  gm.) . 

2.  Tinctura  opii  deodorati  (U.  S.).  Dose  5  to  15  m.  (or  0.3  to 
I  mil.). 

3.  Tinctura  opii  camphorata  (U.  S.)  —  "  Paregoric."  Dose 
for  adult  i  to  4  dr.  (or  4  to  16  mils.). 

4.  Codeine  sulphas  (U.  S.)  |  to  |  gr.  (or  0.008  to  0.032  gm.). 

5.  Diacetyhnorphinae  hydrochloridum  (U.  S.). 

6.  Scopolaminse  hydrobromidum  (U.  S.).  Dose  1/ 150  to  i/ioo 
gr.  (or  0.00033  to  0.00065  gni-)  subcutaneously.  Combined  with 
a  small  dose  of  morphine  it  may  act  better  than  either  alone. 


DIGITALIS.     (U.  S.) 

Action  in  therapeutic  doses  is  comparatively  slight  on  the  normal 
heart  or  when  symptoms  are  not  due  primarily  to  cardiac  insuffi- 
ciency. 

Absorption  is  variable  and  complete  excretion  is  slow.  Effects 
may  persist  for  two  weeks. 

In  well  marked  cases  of  cardiac  insufficiency  the  following  evi- 
dences of  beneficial  action  of  the  drug  should  be  looked  for : 

1 .  Slowing  of  the  pulse  rate. 

2.  Diminution  of  irregularity. 

3.  Increase  in  systolic  blood-pressure  when  it  has  been  sub- 
normal or  decrease  when  it  has  been  excessive. 

4.  Diuresis  if  there  has  been  cardiac  dropsy. 

5.  Diminution  of  respiratory  rate. 

6.  Relief  from  pain  and  distress  symptomatic  of  cardiac  in- 
sufficiency. 


1^77] 

Toxic  Effects.  Tachycardia  or  bradycardia  with  irregularity, 
heart-block,  pulsus  alternans,  fall  of  blood-pressure,  oliguria, 
vomiting,  headache.  These  effects  may  develop  as  a  result  of  the 
cumulative  action  of  digitalis  if  suitable  initial  dosage  is  continued 
for  many  days. 

Indications.  Myocardial  insufficiency  in  general,  with  or  with- 
out valvular  disease.  Almost  useless  in  circulatory  weakness 
resulting  from  vascular  dilatation  or  from  depletion. 

Tachycardia,  pei"  se,  does  not  call  for  digitalis. 

Contraindications.  When  increase  of  blood-pressure  would  be 
dangerous,  e.g.,  cerebral  hemorrhage. 

When  heart-block  is  developing  use  digitalis  cautiously  if 
at  all. 

Selection  of  Preparation.  The  strength  of  digitalis  varies  so 
much  that  physiological  standardization  is  essential  and  should  be 
demanded.  The  "  cat-unit "  method  of  standardization  has 
proved  valuable.  To  attain  the  best  results  prescribe  the  same 
preparation  from  the  most  reliable  available  source.  Either  the 
tincture  or  the  powdered  leaves  made  up  into  soft  pills  are  con- 
venient and  satisfactory  when  made  from  active  leaves 

Administration.  The  dose  of  the  tincture  is  from  5  to  30  min. 
/.  i.  d.  (or  0.3  to  1.85  mils.)  given  in  water;  or  from  one  to  nine 
pills  of  I  grain  each  (or  0.065  g"^-)  daily. 

Higher  initial  dosage  may  be  required  in  severe  decompensation 
or  when  it  is  important  to  get  the  full  effect  of  the  drug  promptly. 

If  after  48  hours  neither  beneficial  nor  toxic  effects  are  observed, 
the  dose  should  be  increased. 

When  benefit  begins  to  follow  the  use  of  the  higher  dosage,  the 
dosage  should  be  reduced  to  prevent  the  cumulative  toxic  effects. 
It  is  believed  that  free  action  of  the  bowels  tends  to  present  toxic 
effects. 

Doses  of  the  tincture  should  be  measured  in  a  graduated  glass 
because,  when  prescribed  in  drops,  the  usual  result  is  that  the 
patient  receives  a  dose  much  smaller  than  intended. 

Through  the  work  of  Eggleston  *  and  others,  knowledge  of 
digitalis  therapy  has  gained  much  in  precision  and  certain  new 


*  Eggleston:  Am.  Jour,  of  the  Med.  Sc.  Nov.  1920,  p.  625.  This  is  a  very  valuable 
article  and  gives  references  to  other  important  works  on  digitalis.  Luten:  Jour,  of 
A.M.A.  Jan.  i,  1921. 


[279] 

concepts  have  been  introduced.    The  most  important  of  these  is 
the  use  of  massive  initial  doses  with  the  object  of  obtaining  effects 
more  promptly.     Eggleston  describes  his  method  as  follows: 
"  From  one  to  two  days  are  required  for  digitalization. 
During  the  first  twenty-four  hours  a  dose  of  4/10  gram 
(gr.  vi  or  gr.  vii)  of  the  powdered  leaf  or  4  cc.  (dram  i)  of 
the  tincture  should  be  administered  every  six,  hours,  day 
and  night  for  four  doses.    On  the  second  day  the  dose 
should  be  reduced  one-half  and  the  interval  may  be 
shortened  to  four  hours,  giving  four  doses  per  day  and 
none  at  night.    This  latter  dose  and  interval  should  be 
continued  until  full  digitalization  is  secured." 
This  method  can  only  be  used  safely  when  the  patient  is  under 
close  observation  and  in  the  care  of  an  experienced  nurse.     It  has 
the  advantage  that  benefit  may  be  expected  from  the  drug  in 
from  12  to  24  hours. 

As  an  emergency  measure  20  to  30  min.  (1.2-2  mils.)  of  the 
tincture  may  be  injected  intramuscularly.     It  is  locally  irritating. 
Substitutes. 

(i)  "  Digitan  "  f  Dose  i  to  4  tablets  in  twenty-four  hours. 
Each  tablet  contains  i|  grs.  (0.097  gm.)  of  digitan  and  is  about 
equal  in  strength  to  15  min.  (i  mil.)  of  the  most  active  tincture  of 
digitalis.  The  therapeutic  effect  is  the  same  as  that  of  other 
preparations  of  digitalis  but  effects  may  be  expected  in  from  12  to 
24  hours  and  vomiting  rarely  follows  its  use. 

(2)  Strophanthin  (U.  S.)  is  probably  better  than  any  existing 
preparation  of  digitalis  for  intravenous  use.  Its  action  on  the 
heart  when  used  in  this  way  is  like  that  of  digitalis  but  effects  are 
almost  instantaneous.  Solutions  are  liable  to  deterioration. 
Small  repeated  doses  may  be  useful  temporarily  when  digitalis 
cannot  be  taken  by  mouth.  A  full  dose  should  be  given  only  as  an 
emergency  measure  and  should  not  be  repeated  within  24  hours. 
Dose:  o.i  mg.  to  0.5  mg.  The  drug  should  be  injected  very 
slowly  over  a  period  of  not  less  than  five  minutes. 

Contraindication.  If  digitalis  in  any  form  has  been  taken  by 
the  patient  within  ten  days  strophanthin  cannot  safely  be  used 
except  in  very  small  dosage. 

t  U.  S.  p.  (N.N.R.)  first  Introduced  under  the  name  of  "digipuratum."     It  is  ex- 
pensive. 


[28l] 

(3)  Ouabain  (N.N.R.)  is  a  crystalized  strophanthin,  which 
can  be  obtained  in  ampules  prepared  by  Hynson,  Wescott  and 
Dunning.  One  mil.  of  their  solution  contains  0.5  mg.  but  it  should 
be  noted  that  the  ampules  contain  more  than  i  mil.  The  date  of 
manufacture  and  of  expiration  (3  months)  is  placed  on  each 
package. 

This  drug  is  best  employed  dissolved  in  from  4000  to  8000  parts 
of  0.85%  sol.  of  sodium  chloride.  It  can  be  given  either  in- 
travenously or  intramuscularly  in  the  dose  of  0.0005  g^n-  (&"' 
1/120)  which  as  a  rule  should  not  be  repeated  in  less  than  24 
hours.     The  writer  has  had  no  personal  experience  with  this  drug. 


7.    NITROGLYCERIN. 
Glyceryl  trinitrate,  t 

Action.  Lowers  blood-pressure  by  dilating  peripheral  vessels. 
Acts  within  a  few  minutes;  effect  lasts  about  |  hour.  In  the 
presence  of  hypertension  diuresis  may  result. 

Toxic  Effect.  Flushing,  sense  of  fulness  in  head,  throbbing 
headache,  faintness.     Reduction  of  urinary  output. 

Indications.    Angina  pectoris. 

Cardiac  embarrassment  ]    ,        ,  ,  .  , 

Tj     J     ,  [when  due  to  high  pressure. 

Contraindications.     Low  blood-pressure. 

Administration.  Tablet  triturate.*  For  quick  absorption  the 
tablet  should  be  chewed  and  not  swallowed. 

Ordinary  dose,  ywo  gi*-  (oJ*  0.00065  g'^-)  ^^7  be  repeated  fre- 
quently unless  toxic  symptoms  result. 

For  some  cases  aw  gr.  (or  0.00032  gm.),  or  ^V  gi"-  (or  0.0013  gm.) 
is  better.     Larger  doses  may  be  required. 

Substitutes,     i.   Amylis  nitris  (U.  S.).     "  Amyl  nitrite." 

Dose  3  to  5  min.  (or  0.18  to  0.3  mils). 

Acts  very  rapidly.     Effect  very  transient. 

May  act  when  nitroglycerin  fails. 

Put  up  in  "  pearls  "  containing  3  or  5  min.  (0.2  or  0.3  mils). 

Break  pearl  and  inhale  from  handkerchief. 


X  Official  in  the  form  of  Spiritus  Glycerylis  Nitratis  (U.  S.). 

*  Tablets  are  said  to  lose  strength  but  may  remain  good  for  years.     To  test  them 
take  I  tablet  yourself. 


Pearls  f  should  break  easily  but  not  spontaneously. 
2.   Sodii  nitris  (U.  S.).     "  Sodium  nitrite." 
Action  like  nitroglycerin,  but  lasts  longer. 
Best  prescribed  in  watery  solution. 
Dose,  2  grs.  (or  0.13  gm.). 

8.  THEOBROMINAE  SODIO-SALICYLAS.     (U.  S.) 
*'  Theobromine  Sodium  Salicylate." 

Properties.  White  pwd.  v.  sol.  in  water,  taste  unpleasant, 
turns  brown  on  exposure  to  air. 

Action.  Diuretic;  slightly  irritating  to  the  kidneys.  Effect 
is  produced  in  from  twelve  to  forty-eight  hours;  lasts  for  from 
two  to  three  days. 

Toxic  Effect.     Vomiting. 

Indications.  Cardiac  dropsy.  (Useless  or  nearly  so  in  pure 
renal  dropsy.)  Small  doses  sometimes  act  well  in  angina  pectoris, 
p.  51. 

Contraindications.     Acute  nephritis. 

Administration.     In  capsules  or  in  a  cachet  p.  c. 

Dose,  15  grs.  (or  i  gm.)  4  i.  d.  If  no  result  after  48  hours, 
double  dose.  Never  prescribe  it  in  these  doses  for  more  than  3 
days  at  a  time. 

Substitutes. 

1.  Theophylline  (U.  S.).  Dose  3  to  6  grs.  (or  0.2  to  0.4  gm.) 
t.  i.  d.  in  powder  with  water  or  in  capsule. 

2.  If  kidneys  are  sound,  Calomel  may  be  used  in  the  dose  of 
3  grs.  (or  0.2  gm.)  every  four  hours  for  from  twenty-four  to  forty- 
eight  hours  or  even  longer.  To  reduce  danger  of  salivation  take 
precautions  described  under  Hydrargyrum. 

9.  MAGNESII  SULPHAS.     (U.  S.) 
"Salts,"  "Epsom  Salts"  or  "Bitter  Salts." 

Properties.  Colorless,  crystalline,  very  soluble  in  water,  taste 
bitter. 

Action.  Hydrogogue  purge  in  concentrated  solution,  cathartic 
in  dilute  solution. 


I  Allen  &  Hanbury's  are  good. 


[28s] 

Toxic  Effects.  Gastric  irritation  and  vomiting.  If  given  in 
concentrated  solution  it  may  be  absorbed  and  may  then  cause 
severe  poisoning  characterized  by  oliguria,  hematuria,  slow- 
respiration,  paralysis  of  the  intestines,  extreme  weakness  and 
collapse,*  The  urine  in  poisoning  shows  a  very  high  specific 
gravity  owing  to  the  excretion  of  the  drug  by  the  kidney.  These 
effects  are  rare. 

Indications.     Dropsy  or  uremic  states. 

Contraindications.  Weakness,  emaciation,  vomiting,  men- 
struation, pregnancy. 

Administration.  Most  easily  taken  in  a  cup  of  black  coffee 
and  miost  effective  when  taken  i  hour  before  breakfast  or  when 
the  stomach  is  empty. 

Dose.  From  |  to  i  oz.  (or  15  to  30  gm.)  followed  by  half  a 
glass  of  water.  Small  doses  with  much  water  can  be  used  for 
mild  catharsis. 

i  Substitutes,  i.  Croton  oil,  i  to  3  min.  (or  0.06  to  0.2  mil) 
in  pellet  of  butter.  If  placed  on  the  back  of  the  tongue  of  an 
unconscious  patient  it  will  be  swallowed. 

1.   Pot.  bitartrate  and  Comp.  jalap,  pwd.  aa  drach.  i  (or  4  gm.). 

3.  Elaterium  (Br.  '98)  \  gr.  (or  0.016  gm.)  in  tablet,  f 

4.  "  Ten-ten,"  calomel  and  jalap,  aa  grs.  10  (or  0.65  gm.). 

10.    QUININiE  SULPHAS.     (U.  S.) 
"  Quinine." 

Properties.  White,  cryst.,  slightly  sol.  in  water,  taste  very 
bitter. 

Action.  Specific  for  malaria,  antipyretic;  readily  absorbed, 
and  rapidly  eliminated  in  urine. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema;  oc- 
casionally renal  irritation,  amblyopia,  or  cardiac  depression. 

Indications.     Malaria. 

Contraindications.  Idiosyncrasy.  Patients  are  frequently 
mistaken  in  believing  they  cannot  take  quinine. 

Administration.  Ordinarily,  10  grains  (0.65  gm.)  /.  /.  d.  is 
sufficient  to  cut  short  an  attack  of  malaria  in  48  hours.     Larger 


*  Boos:  Jr.  A.M.A.,  Dec.  lo,  1910. 

t  Elaterium  has  seemed  to  act  better  than  Elaterin. 


[287] 

doses  may  be  required  and  especially  in  the  prenicious  forms  of 
malaria  or  in  resistant  cases.  One  of  the  more  soluble  salts  of 
quinine  should  then  be  administered  intramuscularly. 

Quinine  therapy  should  be  preceded,  as  a  rule,  by  moderate 
purgation.     Calomel  is  especially  recommended. 

Treatment  should  begin  as  soon  as  the  diagnosis  is  established. 
The  sulphate  is  best  given  in  capsule,  but  soft  pills  are  generally 
satisfactory.     Pills  which  are  too  hard  may  not  be  absorbed  at  all. 

Within  a  few  days  after  the  fever  has  yielded  to  treatment  the 
dose  of  quinine  should  be  diminished.  Then,  in  order  to  com- 
plete the  cure  and  to  prevent  the  patient  from  becoming  a  possible 
source  of  infection  to  others,  he  should  continue  to  take  quinine  in 
the  dose  of  lo  grains  daily  for  three  months.  This  dose  should  be 
taken  2-4  hours  before  the  time  of  day  at  which  the  chills  generally 
appeared  during  the  most  recent  attack  of  fever. 

Substitutes. 

1.  Quininse  hydrochloridum  (U.  S.):  sol.  in  18  parts  of  water. 

2.  Quinine  dihydrochloridum  (U.  S.) :  sol.  in  0.6  part  of  water. 
These  preparations  are  well  suited  for  intramuscular  injection 

but  this  use  of  quinine  should  be  limited  to  the  pernicious  forms 
of  malaria,  those  resistant  to  ordinary  treatment,  and  to  cases  in 
which  vomiting  prevents  the  use  of  quinine  by  mouth  because 
local  necrosis  and  pain  generally  occurs  at  the  site  of  injection. 
Grail  and  Clarac  say  that  local  irritation  can  be  avoided  by  using 
solutions  not  more  concentrated  than  1-20.  The  usual  daily 
intramuscular  dose  of  either  of  the  above  preparations  is  from  7  to 
12  grains  (0.455  gm.  to  0.780  gm.)  but  Craig  recommends  for 
pernicious  malaria  injections  of  71  grs.  (0.4875  gm.)  of  "  quinine 
bihydrochloride  "  repeated  every  four  hours  if  necessary  and 
Manson  says  that  30  grs.  (2.0  gm.)  may  be  given  in  enema. 


II.   SODH  SALICYLAS.     (U.  S.) 

Properties.  A  white  powd.  sol.  in  water,  taste  sweetish  and 
saline. 

Action.  Analgesic,  antipyretic,  and  diaphoretic.  It  has  a 
curative  effect  in  some  forms  of  rheumatism  (see  rheumatic  fever, 
p.  93).     It  increases  nitrogen  elimination  in  the  urine  and  acts  as 


[289] 

a  cholagogue  and  diuretic.  It  is  readily  absorbed  and  is  elimi- 
nated by  the  kidney. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema,  de- 
lirium and  gastro-enteric  disturbance.  It  is  slightly  irritating 
to  the  kidneys  and  unless  given  with  alkali  may  cause  albuminuria. 
Very  large  doses  may  cause  drowsiness  or  coma. 

Indications.  Rheumatic  fever  and  various  forms  of  "  rheu- 
matism." Useless  in  the  gonorrheal  and  in  some  other  types  of 
arthritis. 

Contraindication.    Acute  nephritis  or  idiosyncrasy. 

Administration.  In  tablet  or  capsule  followed  by  a  full  glass 
of  water  unless  the  heart  be  insufficient.  If  large  doses  are  to  be 
used  prescribe  also  enough  sodium  bicarbonate  to  render  the 
urine  alkaline  and  see  that  the  bowels  be  kept  free. 

Dose.  For  rheumatic  fever,  10  grs.  (or  0.65  gm.)  of  sodium 
salicylate  every  hour  until  the  patient  is  relieved  of  pain;  then 
10  grs.  (or  0.65  gm.)  every  4  hours  until  convalescence  has  been 
established;  then  20  to  30  grs.  (or  1.3  to  2  gm.)  daily  for  a  month 
or  more  to  prevent  relapse.  If  toxic  effects  occur  the  medicine 
must  be  omitted  until  they  pass  off.  It  can  then  be  resumed  in 
smaller  dosage  or  in  different  form.  A  vehicle,  such  as  essence  of 
pepsin,  may  be  helpful.  For  mild  cases  of  arthritis  smaller  doses 
may  be  sufficient.  In  chronic  "  rheumatism  "  5  to  10  grs.  (or 
0.3  to  0.65  gm.)  taken  2  to  4  i.  d.  may  promote  comfort. 

Substitute,  i.  Salicinum  (U.  S.).  Action  and  uses  like  so- 
dium salicylate  but  weaker  and  causes  less  gastric  disturbance. 

2.  Methyhs  salicylas  (U.  S.).  "  Oil  of  wintergreen."  Should 
be  given  in  milk,  or  in  capsule.     Dose,  1 5  to  30  min.  (or  i  to  2  mils). 

3.  AcetylsaHcylic  acid,*  ("  aspirin  ").  Dose  as  for  sodium 
salicylate. 

12.  HEXAMETHYLENAMINA.     (U.  S.)  f 

Properties.     Crystalline,  readily  sol.  in  water. 
Excretion.     Chiefly  in  the  urine  in  the  form  of  ammonia  and 
formaldehyde  or  unchanged. 
Action.    When  formaldehyde  %  is  set  free  it  acts  as  a  urinary 


*  Not  official. 

t  "Urotropine,"  and  "Formin,"  are  proprietary  names  applied  to  Hexamethylena- 
mina.     (N.N.R.) 

X  May  give  Fehling's  reaction.     (Bastedo.) 


L  291  J 

antiseptic.  When  the  dmg  is  excreted  unchanged,  as  often 
happens,  it  is  inefficient.     It  acts  only  in  an  acid  urine. 

Toxic  Effects.  Renal  irritation  and  hematuria,  painful  mic- 
turition and  pain  in  the  region  of  the  bladder. 

Indications.  Especially  useful  in  typhoid  fever  to  prevent 
bacilluria  and  cystitis.  It  may  act  well  in  other  cases  of  cystitis 
or  pyelitis. 

Contraindication.    Acute  nephritis. 

Administration.  In  capsule  or  tablet.  Dose  5  to  10  grs.  (or 
0.3  to  0.6  gm.)  /.  /.  d.  with  a  full  glass  of  water.  When  the  urine 
is  alkaline  or  neutral,  sodium  acid  phosphate  *  in  the  dose  of  10 
grs.  (0.65  gm.)  or  more  if  needed  can  be  prescribed  to  change  its 
reaction,  but  this  drug  should  not  be  administered  with  Hexa- 
methylenamine  because  they  are  incompatible  (Bastedo). 

LIST  II. 

VALUABLE  DRUGS 

AND  NON-MEDICINAL  PREPARATIONS. 

Page 

1.  Pills  of  Ferrous  Carbonate,  "Blaud's  Pills" 293 

2.  Sulphonethylmethane,  "Trional" 293 

3.  Bromides 293 

4.  Acetphenetidin 293 

5.  Powder  of  Ipecac  and  Opium 295 

6.  Codeine 295 

7.  Sodium  Bicarbonate 295 

8.  Bismuth  Subnitrate 295 

9.  Mild  Mercurous  Chloride,  "Calomel" 295 

10.  Castor  Oil 297 

1 1 .  Cascara  Sagrada 297 

12.  "Russian  Oil" 297 

13.  Agar 299 

14.  Vaccine  Virus 299 

15.  Antityphoid  Vaccine 299 

16.  Tuberculin 301 

17.  Normal  Salt  Solution 301 

18.  Alcoholic  Beverages  301 

*  Not  official. 


[293  J 

SYNOPSIS  OF  LIST  II. 

1.  Pilulge  ferri  carbonatis.     (U.  S.)     "  Blaud's  Pill." 
Action :  rubifacient,  slightly  constipating,  turns  stools  black. 
Used  especially  in  chlorosis  and  secondary  anemias. 

Dose :  pills  of  5  grs.  each  (or  0.3  gm.) ;  i  to  2  /.  i.  d.,  p.  c. 
Substit.     I.   Ferrum  reductum.     (U.  S.)     Dose,   i   to  3  grs. 
(0.065  to  0.20  gm.)  3  or  4  /.  d.  in  pill  or  powd. 

2.  Liquor  ferri  et  ammonii  acetatis.  (U.  S.)  "  Basham's 
mixture."     Dose,  i  dr.  (or  4  mils). 

2.  Sulphonethylmethanum.     (U.  S.)     "  Trional." 
Action:  hypnotic,  sol.  in  195  water,  more  soluble  in  alcohol. 
Toxic  Effect:  somnolence  and  mental  and  physical  depression. 
Used  for  wakefulness,  sometimes  for  alcoholic  delirium. 

Dose :  for  sleep,  5  to  1 5  grs.  (0.3  to  i  gm.)  in  powd.  by  mouth. 
Larger  doses  may  be  used  for  delirium. 

Prescribed  in  powder  by  mouth  with  water  or  in  sol.  by  rectum. 

Substit.  "  Veronal."  (U.  S.  p.  and  t.,  N.  N.  R.)  Dose,  as 
for  trional  in  powd.  or  tab. 

3.  (i)    Sodii  bromidum.     (U.  S.)     "  Sodium  bromide." 

(2)    Potassii  bromidum.     (U.  S.)     "  Potassium   bromide." 

Action:  Mild  sedative,  lessens  reflex  excitability.  Slightly 
irritating  to  the  stomach. 

Toxic  Effect :  Vomiting,  acne,  coryza,  somnolence. 

Used  for  nervousness,  wakefulness,  epilepsy,  and  to  ward  off 
alcoholic  delirium. 

Dose :  Usually  5  to  1 5  grs.  (or  0.3  to  i  gm.)  /.  i.  d.,  or  a  single 
dose  at  night  for  sleep. 

Much  larger  doses  may  be  required  for  epilepsy  and  for  alcoholic 
patients. 

Prescribed  in  watery"  solution  by  mouth  well  diluted  and  p.  r., 
or,  occasionally,  by  rectum. 

4.  Acetphenetidinum.     (U.  S.)     "  Phenacetin."  * 

Action:   analgesic,  antipyretic,  mild  diaphoretic,  and  sedative. 
Toxic  Effect :  circulatory  depression. 

Used  especially  for  migraine  and  occasionally  for  other  painful 
conditions. 
Dose:  5  to  15  grs.  (or  0.3  to  i  gm.)  in  tab.  or  powder.    A  small 


*  Bayer's  is  the  best. 


dose  may  be  repeated  in  an  hour  or  more  if  necessary.     Prescribe 
with  caffein  citrate,  i  gr.  (or  0.065  g^^-)- 

5.  Pulvis  ipecacuanhse  et  opii.     (U.  S.)     "  Dover's  Powder." 
Action:    mild  opiate:    hypnotic,  sedative,  diaphoretic,  anti- 
pyretic and  analgesic;  slightly  constipating. 

Toxic  Effect :  When  stomach  is  irritable  vomiting  may  result. 

Used  generally  in  single  dose  in  the  evening  for  malaise  or 
insomnia  in  acute  infections  such  as  "  grippe,"  tonsillitis,  or  the 
exanthemata. 

Dose :  10  to  15  grs.  (or  0.6  to  i  gm.)  in  pwd.  by  mouth. 

6.  Codein  SB  sulphas.*     (U.S.)     "Codeine." 

Action:  mild  opiate  and  sedative.     Slightly  constipating. 

Toxic  Effect :  vomiting,  generally  on  following  day. 

Used  to  allay  unproductive  cough. 

Dose :  I  to  I  gr.  (or  0.008  to  0.032  gm.)  in  tablet,  by  mouth. 

7.  Sodii  bicarbonas.f     (U.   S.)     "Soda."     "  Saleratus." 
Action:  antacid. 

Toxic  Effect :  gastric  disturbance,  not  poisonous. 

Used  for  "  hyperacidity,"  in  acidosis,  and  in  acid  poisoning; 
to  render  urine  alkaline;  and  with  salicylate  in  acute  rheumatism. 

Dose :  |  to  i  dr.  (or  2  to  4  gm.)  3  to  4  /.  d.  with  water  by  mouth. 
Larger  doses  may  be  required  in  acidosis. 

8.  Bismuthi  subnitras.     (U.  S.)     "  Bismuth." 

Action:  mild  astringent  and  antacid.  Combines  with  H2S  in 
intestine  to  form  a  black,  insoluble  sulphide. 

Toxic  Effect :  none  with  therapeutic  dose. 

Used  for  diarrhea,  "  hyperacidity,"  peptic  ulcer,  and  for  in- 
testinal fermentation. 

Dose:  for  diarrhea  10  to  20  grs.  (or  0.65  to  1.3  gm.)  repeated 
after  each  loose  movement.  For  peptic  ulcer  |  doses  of  i  dr. 
(or  4  gm.)  are  used  a.  c.  to  coat  the  ulcer  and  to  relieve  distress. 
Prescribed  in  powd.  by  mouth  with  water. 

9.  Hydrargyri  chloridum  mite.     (U.  S.)     "  Calomel." 
Action:    Mild  purgative  and  supposed  intestinal   antiseptic. 

Diuretic.    Antisyphilitic. 
Toxic  Effects :  as  for  mercury  (p.  267). 
Use  and  Dose :  (i.)  as  a  mild  purge,  either  in  the  dose  of  tts  gr. 

*  Diacetylmorphine  hydrochloride  U.  S.  t.  (N.N.R.)  may  be  preferred. 
t  Magnesii  oxidum  (U.  S.)  is  preferred  by  Dr.  R.  C.  Cabot. 
■     X  Use  a  pure  preparation:  e.  g.,  Squibb's. 


[297] 

(or  0.006  gm.)  every  15  m.  for  8  or  10  doses  and  followed  by  a 
mild  saline  cathartic  i  hour  after  the  last  dose,  or  i  to  3  grs. 
(or  0.065  to  0.2  gm.)  can  be  taken  in  single  dose  at  night  and  the 
saline  on  the  following  morning. 

(2.)  As  a  diuretic:  3  grs.  (or  0.2  gm.)  every  4  hours  for  24  to  48 
hours  or  until  diuresis  begins.  When  using  this  dose  the  usual 
precautions  against  poisoning  must  be  taken  (p.  267).  Prescribe 
in  tablet. 

(3.)  Calomel  is  preferred  by  many  to  salicylate  of  mercury  for 
the  treatment  of  syphilis  by  injection. 

10.  Oleum  ricini.     (U.  S.)     "  Castor  oil." 

Action:  mild  purgative;  acts  in  2  to  6  hours;  after  effect  con- 
stipating. Do  not  prescribe  it  during  menstruation  or  preg- 
nancy. 

Toxic  Effect :  not  poisonous  but  may  be  vomited. 

Dose:  i  to  2  ozs.  or  more  (15  to  60  mils.).  Lemon  juice  or 
brandy  helps  to  disguise  the  taste. 

11.  Fluidextractum  Cascarae  Sagradae.  (U.S.)  "  Fl.  ext.  of 
cascara  sagrada." 

Action:  mild  laxative.     Taste:  very  bitter. 

Toxic  Effect :  irritation  of  bowel. 

Dose :  10  to  30  m.  (or  0.6  to  2  mils.)  at  bed-time  with  water. 

12.  *'  Russian  Oil." 

Petrolatum  liquidum  (U.  S.)  and  "  Russian  Oil  "  are  liquid 
paraffins  under  the  definition  of  the  British  Pharmacopoeia,  but 
"  Russian  Oil  "  is  not  liquid  petrolatum  because  of  a  difference 
between  Russian  and  American  Petroleum.  "Russian  Oil"  is 
more  refined  than  is  ordinarily  the  case  with  liquid  petrolatum. 
The  latter  usually  has  a  yellowish  color  and  an  unpleasant  taste, 
but  the  former  is  colorless  and  tasteless. 

Substitutes  for  "  Russian  Oil  "  should  have  similar  general 
characteristics,  should  be  tasteless,  and  of  high  specific  gravity. 
Lighter  oils  seem  less  efficient,  and  sometimes  escape  through  the 
anus  involuntarily. 

Action:  A  lubricant  which  passes  unabsorbed  and  undigested 
through  the  intestine.  Unlike  olive  oil  it  is  not  a  food,  and  is 
less  apt  to  disturb  the  digestion. 

Used  chiefly  in  chronic  constipation,  alone  or  in  conjunction 
with  other  forms  of  treatment. 


[299! 

Dose:  i  to  3  tablespoonfuls  twice  daily;  preferably  several 
hours  after  a  meal. 

13.  Agar  (U.  S.). 

Action:  Agar  swells  tremendously  by  absorbing  water,  is  not 
digested,  and  does  not  ferment  in  the  intestinal  tract.  Therefore 
it  stimulates  peristalsis  and  helps  to  sweep  out  the  bowel. 

Used  in  chronic  constipation,  generally  in  conjunction  with 
other  forms  of  treatment. 

Dose :  |  to  i  tablespoonful  once  or  twice  daily. 

Administration :  Powdered  agar  can  be  eaten  on  cereal.  Gran- 
ulated agar  can  be  mixed  with  and  washed  down  with  milk  or 
water.    Agar-agar  wafers  are  more  attractive  but  expensive. 

14.  Virus  Vaccinicum  (U.  S.)     Smallpox  vaccine. 

The  living  virus  of  cow-pox  is  used  as  a  prophylactic  against 
smallpox.  The  virus  should  be  fresh,  and  a  "  take  "  or  lesion  of 
cow-pox  is  required  to  confer  immunity. 

Admin,  i.  Clean  skin  with  soap  and  water.  Antiseptics,  if 
used,  must  be  washed  off  lest  they  kill  the  virus. . 

2.  When  dry,  scarify  skin  very  superficially  without  causing 
bleeding.     A  needle  or  any  sharp  instrument  will  serve. 

3.  Apply  virtis.  After  it  has  dried  completely  cover  the  spot 
with  a  sterile  pad  and  secure  it  with  adhesive  plaster. 

4.  When  the  inoculation  "  has  taken  "  the  lesion  should  be 
bathed  with  antiseptics  and  dressed  aseptically  from  time  to  time. 
Secondary  infection  and  much  pain  can  thus  be  avoided. 

Note. —  Virus  is  prepared  by  health  departments  nearly  every- 
where and  is  distributed  free  to  physicians. 

15.  Typhoid  vaccine. 

A  killed  culture  of  typhoid  bacilh  standardized  by  count. 
Used  for  prophylactic  inoculation  against  typhoid  (p.  77). 

In  order  to  guard  also  against  paratyphoid  A  and  B,  a  mixed 
vaccine  is  advised. 

In  general,  three  doses  are  given  subcut.  at  intervals  of  a  week 
or  ten  days  as  follows:  500  million,  1,000  million,  and  1,000  mil- 
lion. 

The  reaction  is  seldom  severe.  There  may  be  fever  and  ma- 
laise. 

The  interval  between  injections  should  not  be  longer  than  10 
days  lest  anaphylaxis  result. 


l3oi  J 

Inoculation  is  strongly  recommended  for  persons  who  travel, 
for  nurses,  physicians,  soldiers  and  others  who  may  be  exposed 
to  typhoid  infection. 

Note. —  Prepared  by  health  departments  *  and  pharmaceutical 
firms. 

1 6.  Tuberculin. 

Used  for  diagnostic  tests  and  for  treatment  in  suitable  cases  of 
tuberculosis.  For  detailed  information  see  "  Early  Pulmonary 
Tuberculosis:  Diagnosis,  Prognosis,  and  Treatment,"  by  John  B. 
Hawes,  2d,  M.D.     (Wm.  Wood  &  Co.) 

There  are  several  kinds  of  tuberculin.  Koch's  old  tuberculin  is 
a  glycerine  extract  of  tubercle  bacilli.     It  is  still  used  extensively. 

17.  Liquor  Sodii  Chloridi  Physiologicus  (U.  S.)  "  Normal 
salt  solution." 

Used  by  hypodermoclysis,  intravenously,  or  by  rectum,  depend- 
ing upon  circumstances  and  object  in  view. 

The  common  solution  consists  of  .85  per  cent  of  sodium  chloride 
in  distilled  water. 

Solutions  are  prepared  also  according  to  other  formulse  which 
contain  calcium  and  potassium  chloride  in  addition  to  sodium 
chloride. 

When  prescribing  specify  formula  desired. 

18.  Alcoholic  beverages. 

A.    (fl)  Spiritus  frumenti  (U.  S.  VIII).     "  Whiskey." 
{b)  Spiritus  vini  GalHci  (U.  S.  VIII).     "  Brandy." 

Uses: 

(i.)  "  Quickly  diffusible  stimulant  ":  dose  by  mouth,  i  drach. 
to  I  oz.  (or  4  to  30  mils).     Dose  subcut.  30  min.  (or  2  mils). 

(2.)  To  promote  appetite;  best  taken  with  meals  and  well 
diluted. 

(3.)  As  a  food  in  malnutrition  when  other  foods  are  not  absorbed 
in  sufficient  quantit}-.  Alcohol  is  especially  useful  in  selected 
cases  of  typhoid  or  septic  infection. 

Dose  I  to  2  oz.  (or  30  to  60  mils)  diluted  with  water  and  repeated 
at  intervals  of  2  to  6  hours.     Larger  doses  are  sometimes  beneficial. 

If  odor  remains  long  on  breath  reduce  dose  or  lengthen  interval. 

Champagne  is  often  borne  better  than  whiskey  or  brandy 
when  the  stomach  is  irritable. 

*  Distributed  free  in  Massachusetts  by  the  State  Board  of  Health. 


J303J 

(4.)  Whiskey  well  diluted  with  water  or  wine  taken  v/ith  meals 
is  beneficial  for  some  elderly  persons  who  are  not  over-fat. 

B.  Beer,  ale,  porter,  or  malt  may  be  prescribed  with  meals  to 
improve  appetite  and  to  promote  increase  of  weight. 


LIST  III. 
DRUGS  COMMONLY  USEFUL. 

1.  Ferrum  reductum.     (U.  S.) 

2.  Liquor  ferri  et  ammonii  acetatis.     (U.  S.)     "Basham's 

mixture." 

3.  diacetylmorphinae  hydrochloridum.     (u.  s.) 

4.  Spiritus  ammonia  aromaticus.     (U.  S.) 

5.  PoTASsii  BiTARTRAS.     (U.  S.)    "Cream  of  tartar." 

6.  POTASSII    CITRAS.       (U.  S.) 

7.  PiLULA    SCILL^   COMPOSITA.       (Br.  'I4.) 

8.  Liquor    antisepticus     alkalinus.     (N.     F.)     "Alkaline 

antiseptic  solution." 

9.  Liquor    sodii    boratis    compositus.     (N.    F.)    "Dobell's 

solution." 

10.  Caffeina  citrata.     (U.  S.) 

11.  Strychnine  sulphas.     (U.  S.) 

12.  TiNCTURA    NUCIS   VOMICA.       (U.  S.) 

13.  Syrupus     hypophosphitum.     (U.  S.)     "Syrup    of     hypo- 

phosphites." 

14.  Syrupus       hypophosphitum       compositus.     (U.  S.  VIIL) 

"Compound  syrup  of  hypophosphites." 

15.  Phillips'  Milk  of  Magnesia.! 

16.  Senna.     (U.S.)    "Senna  leaves." 

17.  Glycerinum.     (U.  S.) 

18.  TiNCTURA  lODI.      (U.  S.) 

19.  TiNCTURA    BELLADONNA    FOLIORUM.       (U.  S.) 

20.  PiLULA       CATHARTICS       COMPOSITE.       (U.  S.)       "  CompOUnd 

Cathartic  Pills." 

21.  Pilule    aloini,   strychnine,    et   belladonne    (N.    F.) 

"A.  S.  and  B.  PiUs." 

f  Proprietary. 


LIST  IV. 

DRUGS  VALUABLE  FOR  OCCASIONAL  USE. 

1.  Thyroid  extract.* 

2.  Liquor  potassii  arsenitis.     (U.  S.)    "Fowler's  solution." 

3.  Pilocarpine  hydrochloridum.     (U.  S.) 

4.  Apomorphine  hydrochloridum.     (U.  S.) 

5.  vinum  colchici  seminis.j     (u.  s.  viii.) 

6.  quininae  hydrobromidum.     (u.  s.) 

7.  Scopolamine  hydro bromidum.     (U.  S.) 

8.  Caffeine  sodio-benzoas.     (U.  S.) 

9.  Oleum  TiGLii.     (U.S.)    "CrotonOil." 

10.  Elaterium.     (Br.  '98.) 

11.  Adrenalin  chloride  solution,  J  1  to  1,000. 

12.  Cocaine  hydrochloridum.     (U.  S.) 

13.  Atropine  sulphas.     (U.  S.) 

14.  Theophyllina.     (U.  S.) 

15.  Emetine  hydrochloridum.     (U.  S.) 

WEIGHTS  AND  MEASURES. 

METRIC  WEIGHT. 

I   kilogram  **  (kg.)  equals  in  weight  i  litre  of  distilled  water  at 
maximum  densit^^,  i.e.^  at  4°  C.  and  760  mm.  pressure. 
I  kg.  =  1000  grams, 

i.o  gm.       =  gram.  (gm.). 
o.i  gm.       =  decigram  (dg.). 
o.oi  gm.     =  centigram  (eg.). 
o.ooi  gm.   =  milligram  (mg.). 

METRIC  FLUID  MEASURE. 

I  L.  =1  Liter  of  1000  milliliters  or  cubicentimeters 

i.o  cc.         =  I  mil. 
0.1  cc.         =0,1  mil. 


*  Not  official.     Burroughs  Welcome  &  Co.'s  extract  is  good. 

t  This  preparation  is  much  weaker  than  the  wine  of  the  root  or  than  the  tincture. 
The  dose,  therefore,  is  larger. 
i  U.  S.  t.  Parke,  Davis  &  Co. 
**  One  avoir,  pound  =  0.453592  Kg. 
One  kilogram         =  2.20462  pounds. 


[307  J 


RELATIVE  TABLE. 

Weight 

Metric 

Apothecary 

I  gm. 

—  ^S-S  grains 

0.1  gm. 

=  1.55  grains 

o.oi  gm. 

=  .155  grains 

o.ooi  gm. 

=  .0155  grains 
Measure. 

Metric 

Apothecary 

iL. 

=    2.1 133  pints  (approx. 

2  pints) 

i.omil. 

=  16.2306  min.  (approx. 

15  min.) 

0.1  mil. 

=    1.623  minims 

APOTHECARIES'  OR  TROY  WEIGHT. 

lb.  I   =1  pound  of  12  ounces. 
SI   =  I  ounce  of  8  drachms. 
3I   =  I  drachm  of  60  grains. 
gr.  I   =  I  grain  (or  0.065  gm-)- 
Note. —  The  Imperial  Standard  Troy  weight  corresponds  with 
Apothecaries'  weight  in  pounds,  ounces,  and  grains  but  it  divides 
the  ounce  into  20  pennyweights  of  24  grains  each.     (U.  S.  D.) 


U.  S.  APOTHECARIES'  OR  WINE  MEASURE. 

0    1=1  pint  of  16  fluid  ounces. 

Fl  I   =  I  fluid  ounce  of  8  fluid  drachms,  (weight  =  455.6 

grs.). 
Fl.  3I   =  I  fluidrachm  of  60  minims. 
Min.  1=1  minim. 
Note. —  The  "  Imperial  Measure  "  used  in  the  British  Pharma- 
copoea  diff"ers  in  some  respects  from  the  above.     One  Imperial 
pint  is  divided  into  20  fluid  ounces,  each  equal  to  7  fluidrachms 
and  41  minims  of  U.  S.  Apothecaries'  Measure. 


[309 


RELATIVE  TABLE. 

Weights. 

Apoth. 

Metric. 

I  oz. 

=  31.10  gm.  (approx.  30  gm.) 

I  drachm. 

=    3.88  gm.  (roughly  4  gm.) 

30  grs. 

=    1.94  gm. 

15  grs. 

=    0.972  gm.  (approx.  i  gm.). 

10  grs. 

=    0.648  gm. 

5  grs. 

=    0.324  gm. 

igr. 

=    0.065  gn^- 

1/4  gr- 

=    0.01620  gm. 

1/6  gr. 

=    0.01080  gm.  (approx.  10  mgm.) 

1/8  gr. 

=    0.00810  gm. 

1/30  gr. 

=    0.00220  gm. 

1/60  gr. 

=    o.ooiio  gm.  (approx.  i  mgm.). 

i/ioo  gr. 

=    0.00065  g"^- 

Measxires. 

Apoth. 

Metric 

I  pint 

=  473.11    mils. 

I  Fl.  oz. 

=    30.00    mils. 

4  Fl.  drach 

.    =     15.00    mils. 

I  Fl.  drach 

.    =      3.70    mils,  (roughly,  4  mils). 

30  min. 

=      1.85    mils. 

20  min. 

=      1.23    mils. 

15  min. 

=       0.92    mils,  (roughly  i  mil). 

10  min. 

=      0.61    mils. 

5  min. 

=      0.305  mils. 

I  min. 

=      0.06    mils. 

ABBREVIATIONS. 

U.  S.                  United  States  Pharmacopoeia,  9th  Rev. 

Br.                     British  Pharmacopoeia 

N.  F.                  National  Formulary,  4th  Ed. 

U.  S,  p.  and  t.  United  States  patent  and  trademark. 
N.  N.  R.  New  and  Nonofficial  Remedies,  1921. 

U.  S.  D.  United  States  Dispensatory,  20th  Ed. 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

J 

\lr\^    I  't     \^^*-:^'! 

C2e(G38)M50 

RC50  Sh2 

1921 
Shattuck 


